Maternal & Child Health

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Contents

COVER PHOTOGRAPHY Kate Holt

Editor Cordelia Jenkins Production editor GeorgeKyriakos Artdirector Kostya Penkov Designer HarrietThorne Picture editor Michael Crabtree Sub editor Philip Parrish

Special reports editor Leyla Boulton Global advertising sales and strategy Opinion Features director Dominic Good Commercial director Alexis Jarman 09 04 28 ProjectManager Nathalie Ravier JOANNE LIU GLOBAL VIEW BREASTFEEDING Advertising production The provision of emergencycareisvital Innovations in healthcareaim to ease Manynursing mothersinPoland feel Daniel Macklin even in timesofgreat uncertainty thepressures affecting mothersand likepariahs due to social conservatism, their children around the world and lack of sound medical advice CONTRIBUTORS 33 Maggie Fick West Africa OONA CAMPBELL 10 34 correspondent Preventing maternal deaths requires MIGRANT MOTHERS ABORTION LucyHornby DeputyBeijing bureau morethan drugs and tools, we need Europe’s refugeecrisis shows no sign of El Salvador’s anti-abortion laws result in chief bettermanagement abating, with women and children the women jailed formurder and doctors AndrewJack Head of curated content most at risk of ill health working in acultureofsuspicion and editor of FirstFT 58 AmyKazmin South Asia bureau chief DESMOND TUTU 14 42 Aimee Keane Interactive journalist Childmarriage harms our human SKIN TO SKIN MATERNALMORTALITY Samantha Pearson Brazil family.Itmust be stopped The application of alow-techand SierraLeone’s government must gain correspondent effective waytoreduce deaths of the trust of its people if it is to address Adam Thomson Former FT Paris prematurebabieshas been slow in India its rising maternal death rate correspondent Innovators Zosia Wasik Warsawreporter 18 50 Jude Webber Mexico and Central 17 CAESAREAN BIRTH FAMILYPLANNING America correspondent Cameroon’s kangaroo mother care As China relaxes its one child policy, the High fertilityrates and an economic FinlayYoung Freelance journalist 27 government is dissuading womenfrom crisis in Nigeria slowprogresson Developing the Odón device taking on the risk of C-sections maternal health 41 Providing medical 24 52 equipment across Kenya LIVESUNDER STRAIN FERTILITY 49 Evidence is growing of alink between Chad’ssocial traditions and poverty

T Maternal and child mortality rates Uganda brings health advice Zikaand birth defects and poorer have trapped this countryinacycle of from World Bank data HOL and medicine at home communitiesare particularly vulnerable high birth ratesand high mortality TE Alleditorial content in this report is

KA 51 created by the FT.The Bill&Melinda Gates Foundationfundedour reporting Affordable health insurance in Nigeria buthad no priorsight of thecontent PHOTO:

FT.COM/BIRTH | 3 INTRODUCTION GLOBAL HEALTH

Child mortality rate (under fiveyears old)

Deaths per 1,000 livebirths, 2015

Chad Not available 138.7 1–12.0 12.1 –30.0 Mali 30.1 –51.0 114.7 51.1 –73.0 SierraLeone 73.1 –108.0 120.4 108.1 –156.0 Somalia Central African 136.8 Republic 130.1

Angola 156.9

Number of under-fivedeaths Thousands, top countries(2015)

Pakistan Congo,Dem. Rep. Ethiopia China Angola Indonesia B

India Nigeria 1,201 750 432 305 184 182 169 147

4 |FT.COM/BIRTH Caring for agrowing world

Innovations in healthcare aim to ease thepressures affecting mothersand theirchildrenaroundthe world

By Andrew Jack Graphics by RussellBirkett

orgeOdón, an Argentine car mechanic with atalentfor invention, wokeupinthe middle of the night in 2006 with an idea. He had recently watched an online video showing how to easily extractacorkfrom inside an empty Jwine bottle using an inflated plastic bag. Until then, all of Odón’s patented inventions had been related to mechanics, but it struck him thatnight thatthe technique could be adapted to replace forceps-assisted births. Theidea’spotential also intrigued Mario Merialdi, then co-ordinator of human reproduction at the World Health Organisation. In 2008, he was attending aconference in Buenos Aires and granted Odón a 10-minute meeting after an introduction by amutual friend. “When Isaw the device, Inever went back in [to the conference],”herecalls. Bangladesh Tanzania Afghanistan Sudan Niger Uganda Chad Eight years later,apartnership to develop and commercialise the Odón device —which incorporates asimple applicator,bag and hand pump and requires 119 98 94 89 88 85 83 almostnospecialistknowledgetouse —has advanced substantially.Becton Dickinson, aUSmedical technologycompany, has pledged $20m to the project, Source: WorldBank designed to makethe device affordable in low and middle income countries. “This is atestcase of whether

FT.COM/BIRTH | 5 INTRODUCTION GLOBAL HEALTH

An estimated225mwomen andgirls in developing countriesstill have an “unmet need”for contraceptives

innovation can be taken to scale. It’s really important,” says GaryCohen, president of global health and development at BD.“If it succeeds, it will stimulate further confidence. If it does not, it will send averybad, stifling signal.” Yetitmay be at leastthree years more before the device makes it to market after clinical trials and regulatoryapproval. “If someone had told me it would takethis long, Iwould have been surprised,”saysOdón. Hisexperience demonstrates the scope for simple innovations thatcould help to substantially reduce the 1. unnecessarily high instances of maternal and child illness and death around the world. It also highlights the challenges involved in fostering, nurturing and 2. delivering such innovations. Basic products including medical devices, medicines and diagnostics often already exist, but are not made widely available, including many of the low-costgeneric medicines on the World Health Organisation’s “essential medicines” list. Vaccines, including for measles and yellow fever,have enormous potential to prevent infection and death. Yeteven those thatare available remain underused, as happened during the lastpandemic flu outbreak. That is partly aquestion of cost, but also of governments’ priorities and of capacitytoprocure, store, distribute and administer them. While manyhealth advocates focus their criticism on the high prices thatpharmaceuticals chargefor medical products —and the intellectual property theyretain over them —less attention is paid to the need for more investment in technical aspects of healthcare systems: staffing, training and management. Improving these aspects means holding governments to account. Arecent analysis published in TheLancet, the

Fertility rates World, (children per woman) Africa Asia Europe 7 7 7 7 Forecast 6 Forecast 6 Forecast 6 Forecast 6 5 5 5 5 ON;

4 4 4 4 ST IL S TI MP

3 3 3 3 NC TO SA Y; BB 2 2 2 2 DE BI 1 1 1 1 IE ERENA HARL ;S C 0 0 0 0 LT S: HO TO 1950-55 90-95 2030-35 1950-55 90-95 2030-35 1950-55 90-95 2030-35 1950-55 90-95 2030-35 TE PHO KA

6 |FT.COM/BIRTH Latin 1950-55 America 90-95 /C aribbe Fo 2030- re cast an 35 7 4 2 6 5 3 0 1 Nor 1950-55 thern Ame 90-95 4. rica 3. 2030-3 Fo re cast Chad planning, an Po Seema pr fr her po Lif Niger camp om acticing st influx childbir 5 ei stnatal Sierr mother er bab has nt neighbouring sa 7 4 2 6 5 3 0 1 and Pr he at aL yA of ex bo 4. 3. 2. 1. pr ajadat th ka Dunkirk issue perienced eo migr re egnanc ry u Nigeria car ngar tf and fugee an ne Oce amily e 1950 an si and ar oo n e t y, s ania -55 90-95 to progr tr world. live medical in kangaroo ex well facing providing would to sure modern in de show We suppor tha polic caesarean rat imprisoned as Atul Me pregnancies or risk them and girls mak Go se sus children the and aining t, Alongside Th In Wider tremely vice, 2000, door educa for the under es als. tain, dical th la in but bir their of mos ead as Ga the y. in turn, is case@f and ammes, tes if vite child av 1970s, do women ths 2030-35 un Other It Fo t—w magazine an these de wande, far only care yd ea journal, replica te checklis tion contr tv of across deployment when if also circ wanted replacements, re al Ch veloping mother readers an died umber ference harsh bir improved st lready shor ul on communit bir cast ot for and in ima t.com. the ina’ medical he ums ne at and profiles but ths innov highlights aceptives, such ot th to and ur the Ug te of can ther to ra ag Europe; yw se ts, tes es abor significantly ha and improve following al now tances foc employment. pregnancies, bl of or ma demons 7 4 2 6 5 3 0 gr ft care, 1 who anda at tima Mi ff children countries popularised as at ve ensure ere form e—s sug he of av potential or scale uses ternal family rela ions prena commodities tion describe ll of yh ap children making at ts funding, en targ are av ted originally ge and the already ed meaning tha five Ch ealth tively to till io of ailable. ni on st ma tr up include

Source: UN population la procedures interes ne tha et tal the murder; causes um contr wean ad at tw Sus planning ws, tha across subsidised ha the ex ternal these —p er numbers improving ed solutions: ’s care. t2 work simple ad ve ill lit am re allowing too De tainable i t2 E by which ex st ng av mos impac aceptive 16 tle x versal ar impede itself an if ubbornly de ted tha pe 25m c the velopment ples in the ai ference young, projec the l such projec tic and ers women u cos veloped la the rt “unme ts 20 s tt would in FT approaches recruitment ularly i ble are surg ise of v of se world ta of erious to women t. he health 15 of eb child De plight helping women .C infant as ten El fu tb Fo innov ts nd to their ti or deliver options yw consis its —l too eon OM r velopment around Odón Salv tn high yt nn per e nt to re space see par reduce the in a now one-child ould Go health toda ower s problems he eed frequently ec contac he insur xample, /B and t of nutrition. own at Colombia and 100,000 ador f tnership. tent, women als poores e to essar to fer ’s MDGs IR ions door re e need ”f y, could such out use d and the mak than writer TH fug tilit were ance i or the pa as by ’s n t such y g ths ee | t y as e 7 INTRODUCTION GLOBAL HEALTH

‘AcrossAfrica, thereisa junkyardofequipment that is dumped when it goes wrong’

western stateofKwara, Nigeria. Itsinitial success has spurred debate about the introduction of astate-wide programme, allowing richer individuals to supportthe costs of premiums for the poor. Kenya has introduced an ambitious multi-year contractthatplaces the onus on manufacturers not only to supply medical equipment, but also to maintain it

Maternal mortality ratio Remote living Births attended by skilledhealth staff Until recently,Kenya Per100,000 live births had just ahandfulof (% of total) diagnostic and dialysis North America centres 100 World Middle East &NAfrica Europe &Central Asia (excluding high Sub-Saharan Latin America income countries) Africa &Caribbean Latin America &Caribbean 80 South Asia Europe &CentralAsia East Asia &Pacific North America East Asia &Pacific Middle East &North Africa 60 1000 World

South Asia 800 40 Sub-Saharan Africa

600 2000 2012 Source: World Bank 400

Thetrick is to find the right models and the right 200 partners: whether for-profit and social investors, governmentsand philanthropic donors; or technical advice and expertise from consultants and companies. 0 Ultimately,theyshould be effective enough to win the supportofthe public sector —whether for funding or Mortality rates 1990 95 2000 05 10 15 worldwide co-existence. Babatunde Osotimehin, executive director of the UN Source: World Bank Population Fund and aformer health minister in Nigeria, stresses the importance of ideas thatcan be integrated with government plans and thatreflecttheir priorities. and train health workers in its use. “Across Africa, there Otherwise, theywill never be picked up, he says. is ajunkyard of equipment thatisdumped when it goes Tim Evans, senior director of health, nutrition and wrong,”saysNicholas Muraguri, principal secretaryat population at the World Bank, argues for the need to the country’sministryofhealth. 216 focus on innovations of significant size to ensure they Previously,Kenya had justtwo intensive care units, and maternal deaths per can have impactand be sustainable. “Small showcase ahandful of diagnostic and dialysis centres. Patients in 100,000 livebirths projects are too often unable to gettoscale,”hesays. remote areas were effectively condemned to die, he argues. “Innovative financing and the abilitytoimplement are Thenew multi-year contractwith five multinational essential for real impact.” suppliers offers enhanced supportacross the nation. Much of the innovation required to ease the ill health But some innovations are condemned to fail because of mothers and children is to do with people, systems the technologyinvolvedistoo sophisticated, or because 42.5 and funding. As Arnab Ghatak, asenior partner in global their business model was never sustainable. Anumber public health at McKinseyputs it: “Wehavealot of the deaths of children of projects are only carrying on thanks to donors after under fiveper technologyweneed. It’s really aquestion about delivery several years of funding. 1,000 livebirths and engaging with governments.”

8 |FT.COM/BIRTH COMMENT JOANNE LIU

or conflict, some are not permitted to go to hospital alone, or at all, while others cannot afford to seek out professional medical care. Even before the 2010 earthquakestruck Haiti, which severely damaged or destroyed 60 per cent of its health facilities, the countryhad extremelyhigh maternal mortalityrates. In the aftermath of the disaster,women arrived with pre-eclampsia or eclampsia —serious conditions characterised by high blood pressure, exacerbated by stress. With the construction of its Centre de Référence en Urgences Obstétricales in the capital, Port-au-Prince, MSF is responding to the city’songoing emergencyobstetric care needs. This has included caring for pregnant women with cholera. Obstetric choleratreatment units, supervised by specialised staff, handle the ensuing serious and sometimes life-threatening obstetric complications or premature labour.Offering 148 beds, these units assisted over 6,000 births in 2015. Therisks facedbywomen duringpregnancyand childbirth are compounded when theyare forced to flee their homes due to violence or instability. By the time theyreach safety,these women are in aweakened state and the living conditions thatgreetthem are precarious, further endangering the survival of both mother and baby. When the Ebola epidemic ravagedWestAfrica, newborns entered aworld where hospitals were shut, health staffwerescarce and people were frightened. Feverand bleeding —both common during pregnancy ‘These deaths are —are also symptoms of Ebola, so health staffwere often reluctant to admit pregnant women to hospitals or let them deliver in health facilities, fearing contamination. preventable’ When Iwas in Liberia in 2014,four pregnant women showed up at MSF’sEbola treatment centre, having spent the whole daysearching for aplacetodeliver. During aconflictoratimeofcrisis, womenand their By the time theyreached MSF,theyhad all losttheir babies areattheir mostvulnerable, says JoanneLiu babies. Their plight underlined how vital the provision of emergencycare is, even in times of greatuncertainty. To address this, MSF setupacentre in Hastings, Sierra Leone, with specific obstetric services for Ebola-positive pregnant women in need of tailored care. Medical staff rom London to Aleppo, pregnancyand focused on trying to minimise the mother’s bleeding childbirth are partofthe normal cycleof while in labour and after delivery, to prevent her dying life. Deliveryisbyfar the mostdangerous from haemorrhage. time for both awoman and her baby and the Approximately 830 women die everyday from causes vast majorityofmaternal deaths occur just related to pregnancyand childbirth, according to the Fbefore, during or after delivery, often from World Health Organisation. It is estimated that99per complications thatcannot be predicted. cent of maternal deaths happen in the developing world. Thepre-existing risk of complications thatall women These deaths are preventable. If complications are face can quickly become adeath sentence if skilled identified and addressed quickly,and care is available, medical care is unavailable. the chance of survival is high. During aconflict or atime of crisis, women and MSF provides skilled birth attendance and emergency their babies are at their mostvulnerable. Thefive obstetric care in one third of all the organisation’s Theprovision main causes of maternal death include haemorrhage, projects in 69 countries; over 200,000 deliveries in sepsis (infection), complications resulting from unsafe 2015 were assisted by MSF teams, who additionally offer of emergency abortion, hypertensive disorders and obstructed labour. preventive action such as contraception, prevention of Maternal mortalityrates worldwide dropped by over mother-to-child HIV transmission, prenatal care as well care is vital 40 per cent between 1990 and 2015 but challenges as cervical cancer screening, treatment and the repair of clearly remain. In manycountries where MSF works, obstetric fistula. even in times obstetric care is in aconstant stateofemergency. We mustcontinue to be present and to provide skilled National health systems are disrupted, there is alack of care to the women and girls who need it. of great qualified medical personnel and the necessarymedicines and equipment are not available. Many women in these Joanne Liuisthe international president of Médecins uncertainty places are unable to access medical care due to insecurity Sans Frontières

FT.COM/BIRTH | 9 EUROPE REFUGEES Europe’s migrant mothers

Women andchildrencrossingthe continent areatparticularriskofhealth problems withoutaccess to medicalcare

By Adam Thomson in Calais andDunkirk Photographs by CharlieBibby

astNovember,Mamit stuffed four changes of clothes into ablack leather handbag, grabbed her Bible and left her native Eritrea under cover of night, fearing persecution for her religious beliefs. Tenmonths later,inmid- LSeptember of this year,the 42-year-old mother of twosits on aroadsidebythe Jungle migrant camp in Calais, northern France. It is justafew weeks before the French authorities will begin to demolish the camp and resettle its inhabitants. She is still clutching her Bible, which is now dog- eared and missing its cover.She is also much thinner: Mamit lostnearly aquarter of her body weight after long periods of hunger,dysenteryand other illnesses during her journeyfrom Africa. “I was afat woman when I left home,”she says, her hands tracing aballoon shape 1. around her now-slender figure. “Myfamily would never recognise me now.” More than amillion men, women and children — economic migrants and refugees from war-torn countries —entered Europe by land and sea in 2015 alone. They continue to move into and across the EU,undeterred by the lack of access to medicine or doctors on the journey. Even when theyreach Europe, the greatmajority continue to face health risks, particularly in places such as the heavily populated Jungle camp, which the French government began dismantling in October after years 2. of inaction.

10 |FT.COM/BIRTH 1. Mamit with her Bible and the leather handbag she used to carry her clothes 2. Yabsira’s daughter, left, in the caravan she shared with her mother in the Calais Jungle EUROPE REFUGEES

‘The EU authoritieshave preferredtoturntheir backsinthe hope that the problem will just go away’

Inthe Calais camp, where she had been for five months, Yabsiraand her daughter were living a precarious existence. They tried to gettotheir final destination of the UK manytimes, but she says it proved almostimpossible to jump on to alorrywith achild in tow.Inthe meantime, theysheltered in acramped caravan in the Eritrean section of the approximately 9,000-strong camp. About 1,000 of the camp’s inhabitants were estimated to be unaccompanied minors, the mostvulnerable of whom were being allowed entrytothe UK at the time of the camp’s destruction. Yabsirasaysadoctor in the camp gave her aspray to treatarash thatbroke out on her arms and legs. She has also received abottle of syrup for treating the colds, sore 1. throats and temperatures thather daughter has suffered since arriving at the camp. It is the firstmedical attention the twohavereceived since setting out from Sudan. “The refugee challengeisfirstand foremosta 1. Until recently,whathealthcare there was at the camp humanitarian catastrophe,”argues François Gemenne, Yabsirawith her was thanks not to the French statebut to Médecins Sans amigration studies researcher at France’s Sciences Po daughterinCalais Frontières (MSF), the humanitarian aid organisation, 2. universityand the UniversityofLiègeinBelgium. An Iraqi-Kurdish family and to other non-governmental organisations, such “Theyarrive in Europe having suffered psychological prepares dinner in the as Médecins du Monde. Many experts argue that and physical damageonly to realise that, in Europe, Grande-Synthe camp the lack of official attention given to refugees’ health conditions areoften worse.” 3. provision across Europe is indicative of EU authorities’ Women such as Mamit, and especially those travelling Sidra’sdaughterRenas unwillingness to acknowledgeaproblem thatshows no in Grande-Synthe with children, are often the mostexposed to the signs of disappearing. “Theyhavepreferred to turn their physical and mental ravagesofajourneythatcan take backs in the hope thatthe problem will justgoaway,” months, sometimes years. Reliable figures for migrant says Gemenne. “It’sjustacrisis management mindset.” movements are difficult to pin down. But an asylum At the EU level, some kind of response is finally taking “pre-registration campaign”tocollectdata, launched place, argues Jean-Pierre Schembri, aspokesman for in June by the Greek Asylum Service, showed that44 the European Asylum SupportOffice (Easo), an EU per cent of the more than 20,000 people enrolled were agencyset up to facilitate and co-ordinate practical female. Of those women, almostone in five was travelling co-operation between member states on aspects of with children, and about one in six was pregnant or had asylum, including how to provide healthcare. “Easo is recently given birth, implying far greater health risks for deploying vulnerabilityexperts in the Greek hotspots in women than for men. order to identifyand refer applicants with special needs, Yabsira, a28-year-old mother of afive-year-old including applicants with health issues,”hesays. girl, says she had no idea of the horrors her journey Theagency, which has no specific mandate on health would entail before she fled Sudan along with her then issues, has nonetheless developed guidelines for member four-year-old daughter.AnEritrean by birth, Yabsira states, setting standards for reception conditions of hadbeen living in Sudan with her mother,husband migrants, including access to healthcare. Theguidelines and daughter,and working as amaid, having escaped were only adopted by Easo’s management board this violence at home years before. After her husband was 2. September and their publication is still pending. arrested and subsequently disappeared, Yabsiradecided Meanwhile, Gemenne says individual countries Sudan was no longer safe. continue to undermine EU-wide efforts to co-ordinate “Weleftinabig lorry,”she recalls of the 10-dayleg to amorecomprehensive response to migrants who arrive Libya, the firstpartofathree-month struggle to getto at their borders. “Proposals put forward by Brussels Calais.“There was almostnofood or water,sothe little to improve conditions and harmonise asylum regimes theygaveusIgavetomydaughter.” across Europe have been systematically rejected by In the lorry, Yabsiraslept with her daughter curled up governments, for fear of losing sovereignty,”hesays. in her lap for lack of space. They suffered diarrhoea and An MSF study conducted at the end of 2015, of more vomiting repeatedly on the journey, and had no access than 400 people living in the Calais camp, shows that to anyform of healthcare. Twooftheir fellow passengers health problems are aconstant theme of manyjourneys, died —one fell out of the lorry, the other from dysentery. in particular for women with children, who tend to be

12 |FT.COM/BIRTH pain was so great, but Iwas justtoldthere wasn’t one,” she says. “I spent twodayslikethat; Ithought at one point Iwasn’t going to getbetter.” Formigrants who takeother routes, things are little better.Sidrawas four months pregnant and still suffering acute morning sickness when she setout with her husband and their twoyoung children from her native Iraqi Kurdistan for the UK.She says that travelling with her eight-year-old son and seven-year-old daughter was aconstant worry. “You have to look after them much more because theyget so tired,”she explains. “You also live in fear of losing them because there are so manyother people.” Theworstmoment was their sea crossing from Turkey to Greece, an early stageofacommonly taken route thatinvolves manydaysoftrying to avoid police and border patrol units at multiple international frontiers, including Albania, Macedonia, Serbia and Hungary. “Wespent days on the boatwithout food or water,” she says. “Mychildren were so frightened and so was I. Ithought Iwas going to die.” Nowher family is housed in asmall wooden shelter at amigrant camp setupbyMSF lastyear in Grande- Synthe, asuburb of Dunkirk, 40km eastofCalais. It is tempting to think thattheyare over the worst. Thelast rays of sunlight are starting to fade, and Renas, Sidra’s seven-year-old daughter,isdressed in apairofMickey Mouse pyjamas and playing with other children, while a group of older girls sit on stools plaiting each others’ hair. Several Kurdish families staying at the camp have come together for the evening to share donated meat and rice, which the women are busy preparing over small wood fires. Washing dries on twolong clothes lines and Sidratells her children to pick up some half-broken toys theyhaveleftinthe dirt. Grande-Synthe houses about 2,500 people, mostof them Kurds —and mostly families with small children. There are some rudimentaryhealth facilities at the camp, thanks to amodestmedical centre established by MSF at the startofthe year which is now run by Utopia 56, avolunteer-based organisation, and local health authorities. Since February, MSF has carried out at leasttwo vaccination campaigns for 2,000 adults at Calais and 3. 500 at Grande-Synthe. They also vaccinated about 250 children aged under six —200 in Grande-Synthe more vulnerable to sickness because of the physical and 50 in Calais —againsttuberculosis, polio, tetanus, demands of the journey, as well as the factthattravelling and gave them the triple MMR vaccine. But in spite of with children can makethe going slower. that, families staying at Grande-Synthe still saythat Thestudy found, for instance, thatalmosttwo-thirds theysuffer continual health problems, ranging from of respondents suffered at leastone health problem persistent respiratoryillnesses and stomach infections during their journey, with acute respiratoryinfections by to rashes and sores. far the mostcommon illness. It concluded thataccessing Sidraand herfamily have been in the camp for 45 days. healthcare is the hardestinLibya, where people wanting They have tried to smuggle themselves into the UK three to enter Europe are held for weeks at atime as theywait times, each time leaving everything behind except for their for passageacross the Mediterranean to Italy. sleeping bags. But she says thatsneaking into alorryat Mamit, who left her twochildren behind in Eritrea night with twosmall children is justtoo difficult.Now that because she could not afford the fee the smugglers were Sidraissix months pregnant, and wondering how she will demanding, says her time in Libya was the mostdifficult gettoher finaldestination, doubts are starting to creep in of the entire journey. “I waited for twomonths in abig about where her next childwill be born.“Istill hope that hangar in thatcountry,”she says. “There musthavebeen it will be England,”she says. “But I’mnolonger as sure as 600 of us in there. There was no room and the only thing before.” theygaveuswas pasta, dayafter day.” In Calais, as the makeshiftstructures of the Jungle During the wait for the boattoItaly,she fell ill with camp are taken down, the future for Mamit, Yabsiraand severe stomach cramps. “I asked for adoctor because the her daughter,isablank.

FT.COM/BIRTH | 13 INDIA KANGAROO MOTHER CARE Up close and personal

Aproject wheremotherscoach other women to breastfeed earlyand hold theirbabiesskin to skin aimstoreduceneonatal deaths

By AmyKazmin in UttarPradesh Photographs by Serena De Sanctis

hen Sushma Sahu gave birth to her firstson six years agoinavillagein Uttar Pradesh, India’smostpopulous state, her mother-in-lawasked the local Hindu priesttorecommend an Wauspicious time to startbreastfeeding the baby.The priestset atimeonthe infant’s third day of life. In the meantime, the newborn would be fed with honeyand water then cow’s milk. “Myfirsttime, Ididn’t know anything,”saysSahu. “I trusted my mother-in-law and whatever she was saying.”

But three years later when Sahu gave birth to her 1. second child, adaughter,the nurse in the primaryhealth care centre told her to startbreastfeeding immediately, as recommended by the World Health Organisation to ensure newborns gettheir mother’s firstmilk (known as Lab, aresearch organisation, has involved mothers like colostrum). Colostrum is rich in protective antibodies, Sahu being trained as “life coaches” and then paid to vitamin Aand proteins, and is only produced in the advise women during their pregnancies and in the first firstfew days after childbirth. Sahu did as the nurse month after their babies are born. Theaim is to entice suggested. “I also felt likebreastfeeding, so when the women to changetheir pre- and post-partum practices nurse told me, Ididn’t really wait for anybody,” she says. —including adopting early breastfeeding and skin-to- NowSahu is one of asmall group of Indian mothers skin contact, which together are known as “kangaroo who are trying to persuade others to breastfeed their mother care” —and measurably cutnewborn deaths. newborns straight after birth and to provide skin-to-skin “People don’t need messages, theydon’t need contacttohelpkeep them warm. Thewomen are partof information —theyneed afriend theycan trust,” ayear-old experiment aimed at reducing Uttar Pradesh’s says VishwajeetKumar,founder of the Community persistently high rates of infant mortality. Empowerment Lab. “Ifyou go and tell them something, Theproject, led by the CommunityEmpowerment it doesn’t changeanything. Youneed to work with them.

14 |FT.COM/BIRTH 2.

babies who might otherwise have been put in incubators —had these been available. In 2003 and 2004, impressed by the success of these simple techniques, Dr Kumar and his colleagues carried out astudy to see whether theycould be used to reduce infant mortalityinrural Uttar Pradesh, where mostwomen were having their babies at home, loyal to traditional practices for the care and handling of newborns. Theresults were clear: the study showed thatinfant mortalityinIndian villages could be reduced by 54 per cent if newmothers adopted early breastfeeding and held their babies close for long periods of time. The impactwas especially significant for premature or low- birthweight babies, who are at the greatestrisk. “This is the mostpowerfulintervention we know of,” Dr Kumar says. GaryDarmstadt, associate dean for maternal and child health at Stanford UniversitySchool of Medicine in the US,acknowledges the global benefits: “A lot of great evidence has been gathered on the impactofkangaroo care on preterm, low-birthweight babies. Themortality reduction in thatpopulation is 40-50 per cent,”hesays. But despite the weight of such evidence, Indian public health experts have struggled to figure out how to persuade more rural women to adopt techniques that are at odds with traditional methods of babycare, as 1. There is no shortcut to these things —you need to well as the demands of rural life, where daughters-in- Amother and babyin navigate, negotiate. Youneed to nudge.” laware expected to do much of the heavy work for large the kangaroo careunit Public health professionals believe simple practices extended families, including preparing food, tending to at Veerangana Avanti Baiwomen’s hospital such as kangaroo mother care could help reduce India’s livestock and crops, and fetching water. in Lucknow, Uttar high infant mortalityrate: 700,000 newborns die within “If you want to be able to provide this care to the baby, Pradesh amonth everyyear.Inthe stateofUttar Pradesh alone, you have to think about the broader elements of the 2. 240,000 newborns die each year —about the same system you are trying to makethathappen in,”saysDr Annapoorna Verma, a number of deaths as were caused by the 2004 Indian Darmstadt. “If the system is not supportive of the lifecoach Ocean tsunami. practice, it’s verydifficult for the mother to provide that Kangaroo mother care was originally developed in care.” Colombia nearly four decades ago, when doctors in Nearly 70 per cent of Indian babies are now born in an overcrowded, poorly equipped hospital found the some form of health centre —adramatic shiftfrom practice could help save premature or low-birthweight adecade ago, when mostbabies were born at home.

FT.COM/BIRTH | 15 INDIA KANGAROO MOTHER CARE

1. Avillage in Shivgarh district in Uttar Pradesh 2. Akhteri Bano with her babyduring her first postnatal visit from lifecoach Annapoorna Verma

1.

Nurses in India’soverstretched and understaffed primary healthcare centres might briefly advise women, but theyhavelittle capacityfor sustained intervention, or to override the wishes of powerful mothers-in-lawattached to old ideas. Many women are sent home from clinics — or simply leave —within an hour or twoofgiving birth, often before breastfeeding their babies. 2. Traditional newborn care practices are rooted in Hindu notions of ritual purityand impurity, which affect how both mothers and babies are treated immediately Mortality rates each household, theydetermine which family members after birth. In Hindu societies, awoman’s menstrual in India will dictate newborn care practices and trytofind out blood is considered impure, as are the blood and fluids how newbabies have been cared for in the recent past. associated with childbirth. “Theytry to figure out who is making decisions and get In Uttar Pradesh, newmothers are kept in some sense of whatfamily [childcare] practices are,”says confinement for up to 40 days after childbirth and Aarti Kumar,the co-founder of the group. newborns are vigorously scrubbed —sometimes In September,Annapoorna Verma, a30-year-old in cold mud —topurifythem, which can lead to coach, called on Akhteri Bhano, who was already back at hypothermia. Colostrum is traditionally seen as dirty 556 home in her villageofBhaunsi, hours after giving birth and harmful for the baby.Asof2014, fewer than a maternal deaths per to her third child at the communityhealth care centre quarter of newborns in Uttar Pradesh were breastfed 100,000 livebirths in Shivgarh 12km away.Verma weighed both mother within an hour of birth. and baby and took their temperatures. She then showed Dr Kumar’s idea —now being tested in asmall- Bhano how to hold the baby skin-to-skin to keep him scale pilot study —istosee whether his “life coaches” warm in the dark, damp interior room where Bhano was can changethese practices. Thecoaches, all mothers to spend at leastaweek recovering. themselves, and mostly collegegraduates, makepre- In anearby village, Sahu was calling on Rukhsana and postnatal visits to prepare mothers-to-be for birth 48 Khatoon, 22, who was in her second trimester.After and its aftermath, to trytoinspire the women and their deaths of children weighing her and taking her blood pressure, Sahu talked families to adopt newpractices. under fiveper with the young woman and her husband about foetal 1,000 livebirths “Wetry to identifywomen in the villagethat development. She explained to the couple thatKhatoon [mothers] can look up to,”saysDrKumar.Each coach should eatnutritious, high-protein foods such as eggs, in the pilot study has been responsible for 600 families. milk and vegetables to help the baby grow. They trytoengagewith everypregnant woman in their On her next visit, she says, the talk will turn to area, making aseries of three prenatal visits followed postnatal care. Khatoon’s mother-in-law, Islamunisa, by three visits in the month after the birth, including says the newborns in their family are traditionally given on the daythe baby is born. Currently there are only 10 water and honeyand goat’s milk for afew days before coaches, but the preliminaryresults —measured against breastfeeding begins —villagers believe milk will not acontrol group in an area with no intervention —are arrive until several days after the birth. They also throw encouraging. Theinitiative will soon be scaled up to 100 the colostrum away in aritual where it is castonthe or 150 coaches, Dr Kumar says. ground as an offering to the earth. In their meetings with pregnant women, the coaches “It’satradition,”saysIslamunisa. “Wedon’t know why share videos on atabletdevice and describe their own we do it.”But it is atradition thatSahu will trytochange experiences of childbirth and caring for their babies. In rather than preserve.

16 |FT.COM/BIRTH INNOVATORS CAMEROON Skin to skin

In Cameroonkangaroomother care is beingpromotedasacheap and effective waytocarefor newborns. By Andrew Jack

Theproject The Cameroon government, in conjunction with the Kangaroo Foundation, Grand ChallengesCanada (a Canadian government-funded innovation fund), Social Finance (a UK non-profit) and the World Bank’s Global Financing Facility,is developing aperformance-based financial bond to expand theuse of acheap and effectiveway to carefor premature babiesacross the country.

Theneed Around 18mchildren each year areborn prematurely or underweight, which is the cause of three-quarters of neonatal deaths.These babiesalsohave ahigher risk of infection, long-term health problems and abandonment by their mothers. Existing techniquessuch as incubatorsare oftentoo costly or impractical to be used in poor regions, without local staff or support.

Howitworks Kangaroo mother care, first devised in Colombia in 1978,is alow-tech approach that usesconstant skin-to-skin care between motherswith their children, exclusive breastfeeding and earlydischarge from hospital with close follow-up.A financial bond, set to launch in 2017,will raise up to $9m to implement“training the trainers” forits use in up to five regions in Cameroon. Investorswill be reimbursed, and will potentially receiveabonus, if targets aremet.

Theimpact Kangaroo carehas been shown repeatedly in rigorous studiestoreduce infection and infant abandonment, and to improve survival and maternal attachment to babies. Apilot study in Douala, Cameroon, that began last year showedthat kangaroo carereduced neonatal mortality from 43 per cent to 28 per cent. Other social impact bonds have demonstrated the potential to raise moneyand link reimbursement to improvedoutcomes.

What is needed next? • Investorsfor the bond, both those seeking social and financial returns. • Donorstocovercosts and bonuses. • Evaluation partnerstodevelop and study outcomes, including access to care, impact on mortality and morbidity. • Forthe Cameroon government overtime to draw the lessons and itself tailor and fund kangaroo careacross the country. • Supporttointegratecarewithother services.

Want to help? Email: [email protected]

FT.COM/BIRTH | 17 CHINA CAESAREANBIRTHS Second time around

Theend of theone-child policy has prompted an official efforttodissuade womenfromtakingonthe risk of C-sections

By Lucy Hornby in Yichang Photographs by Giulia Marchi

nthe fog-wrapped cityofYichang on the Yangtze in the shadow of the world’s largesthydroelectric dam, WanXindi is triumphant as she cares for her new baby daughter.Her second child is healthyand cute, but Wanismostproud of how she came into the Iworld: the old-fashioned way. Anatural birth is in itself an accomplishment in China, where caesarean section rates were, until afew years ago, the highestinthe world. Wanwas one of the many Chinese women who underwent amedically unnecessary C-section when her firstbaby arrived. During her second pregnancy, the 25-year-old went to everyhospital in Yichang, determined to find adoctor willing to allow her to attempt avaginal delivery. In the process, she became afoot soldier in the battle to wean China offits addiction to C-sections. “Wethink of ourselves as tunnel fighters or guerrillas. We find all kinds of ways to makeithappen,”she says. Herweaponofchoice: the smartphone. China’sdecision in 2013 to allow mostcouples to have twochildren has involved undoing social practices entrenched over 35 years of the one-child policy. One

18 |FT.COM/BIRTH Safely delivered Wan Xindi back at her home in Yichang with her newborn daughter Xiaozuo CHINA CAESAREANBIRTHS

‘I learnt so much in these online classes, IfeelIshould shareit. Somemothers don’tresearchmuch’

of those is the preference for C-sections thatare not needed for anymedical reason. All else being equal, C-sections involve aslightly higher risk to the mother than natural births. They also increase the possibilityoflife-threatening complications in future pregnancies, including rupture of the uterus or abnormal attachment of the placenta. These risks become anational problem when nearly half of women approaching their second labour have had aC-section during their first. In the firsthalf of this year already,the number of maternal deaths has climbed by nearly one-third compared with lastyear.“This is due to the second-child policy,”saysMao Qun’an, aspokesman for the National Health and Family Planning Commission. “Weare promoting the idea thatwomen need to consider thatif theychoose C-sections for their firstbirth it could affect their second pregnancy.” “It’sverydangerous,”saysPang Ruyan, vice-president of the Chinese Maternal and Child Health Association, which argues againstC-sections in the Chinese system and advocates agreater role for midwives to assistwith natural births. “The only reason the rateofC-sections is so high is because people expected to only have one child. They didn’t need to think about having another,or the risk of ruptures.” TheWorld Health Organisation puts the optimal 1. C-section ratefor the health of mothers and babies at between 10 and 15 per cent. In the US,with its lawsuit- prone system geared towards medical intervention, the rateis33per cent. In the UK,itis24per cent. In China, decided to attempt vaginal deliverythe second time the rate had reached 46 per cent by 2008 before health around (known as a“vaginal birth after caesarean”, or officials realised the extent of the problem. Some urban VBAC). This option carries its own risks: the firstscar hospitals delivered more than 70 per cent of babies can rupture during the birth. by C-section until the government began to stem the Their inspiration and supportcome from astocky practice about four years ago. professional midwife in her 50s named Zhang Hongyu, As China prepares for an increase in second births, an agonyaunt for women in China hoping to take the health system is moving away from C-sections. control of how their babies are born. From her home In the spirit of the planned economy, public hospitals in the southern island province of Hainan, Dr Zhang have been given C-section quotas. Doctors —some maintains smartphone apps thatextol the benefits of of whom have never attended at avaginal delivery— 2. natural birth. She hosts forums —online and on the are being given crash courses in natural birth or are ubiquitous Chinese social-networking app WeChat being retrained in surgical techniques to reduce the —thatbuzzwith discussions between hundreds of risks in future pregnancies. expectant mothers. Some women text for help and advice China’sofficial C-section ratehas dropped to 35 straight from the deliveryroom. “A lot of people are not per cent, and the health ministryhas embarked on an veryclear about this natural process,”DrZhang says. unusual attempt to changepublic perceptions in favour In the chatrooms, converted mothers likeWan jump of natural birth. Efforts to re-educate Chinese mothers in to answer the concerns of novices to natural birth. rangefromonline classes and smartphone information “I learnt so much in all these online classes, Ifeel I apps featuring healthypink infants, to gory videos of should share it. Some of the mothers, theydon’t bother C-sections thatgoviral on Mother’s Day. to research much,”she says. Thesecond front in the battle to wean China off Wan’sown questfor aVBACwas followed avidlyby C-sections is being led by women likeWan. Some the group. “I’mnot going to live-stream,”she told her mothers likeher who have already had aC-section have followers the dayshe checked into the hospital. She

20 |FT.COM/BIRTH 3. With wealth comes improved health

China has achievednotable success inthe past 15 yearsinimproving maternal health and bringing down its child mortality rates—twoofthe eight Millennium Development Goals that the UN established in 2000.Its high population means such gains in China translateintosurvival for hundreds of thousands of women and children. That success is partly aresult of the country’srapid increase in wealth, which has led to improvements in nutrition forpregnant women and babies. The statehas also been able to invest moreinmedical 1. nonetheless proceeded to text updates. “The pain is care, including prenatal check-ups and neonatal Wanwith Xiaozuo bearable,”read one. “Theywere all waiting to see if I intensivecareunits. and her son Pan could do it. I’ve inspired alot of them,”she says. “Before, some babiesweresimply not treated Youhe,aged two 2. WhydosomanyChinese women choose C-sections? because of family poverty. Butnow fewerand Wanwhile pregnant Doctors blame the families. Newparents and, critically, fewerare left untreated, because parents have with Xiaozuo grandparents, will do anything to makesure their one health insurance and the statehas moreresources,” 3. baby is perfect, including selecting the right dayand says Dr Liu Cuiqing, head of the neonatal unit at The compound where even hour for an auspicious birth. Older people believe Hebei Provincial Children’s hospital in Shijiazhuang. Wanlives in Yichang thatyoung women brought up as single children are too “But that puts morepressureonus, given the pampered to bear pain. Foryears, C-sections have been shortage of doctors, because to treatbabieswith marketed as high-tech and pain-free, with no mention serious conditions requires morework,more of discomfortafter the operation or the risk to future equipment and moretime.” pregnancies. Thereare also darker explanations behind the “When people only have one child theyare overly shining improvements in the statistics. China’s rigid worried,”saysDrZhang. “Theyare worried about loss population control policies—which have been eased of oxygen; theywant to hurryupand getitout and over the past three yearstoallow almost all couplesto have their healthybaby. Plus theythink surgeryis have asecondchild —have meant that most families simple and fast.” would abortatany sign of irregularity in prenatal scans, Women likeWan argue thatnot-so-subtlepressures to avoid apossible health problem in their only child. from doctors scare women (or their husbands and in- Some doctorsand parents admit privately that laws) into asking for medically unnecessaryC-sections. stillborn babies, or newborns with untreatable “The doctors always tell you the worst-case scenarios. conditions, aresometimeshanded to their parents First-time mothers always listen to the doctors,”she says. unregistered so that hospitals do not miss their “Second-time mothers are much more confident.” targets forreducing infant mortality. Lucy Hornby

FT.COM/BIRTH | 21 CHINA CAESAREANBIRTHS

during labour and eatordrink forstrength andhydration 1. ‘The only reason therate in line with traditional practice. Many urban hospitals Wanlooksafter forbid that. “The hospital has me lying on my back and Xiaozuo while her mother Tan of C-sectionsissohighis won’t letmemove!” one expectant mother told Dr Zhang’s Guangchun plays with group. Twelve hours later,denied food or water,“Iran Youhe becausepeopleexpectedto out of energyand went for the C-section”, she texted. 2. Women who have not used the smartphone Wantexts only have onechild’ information apps only receive vague guidance at hospital her chat group birth classes. Thefocus is on maternal nutrition until the eighth month, when mothers-to-be are given acursory explanation of whattoexpectduring the birth. “Open Forovercrowded urban hospitals, the financial classes are likeabig rice bowl or acafeteria —theyaren’t incentives are clear.InYichang, anatural birth costs tailored to personal needs,”DrZhang says. about Rmb3,000 ($450) and requires anurse or As China’shealth system reverses the trends that midwife’s attention for several hours. AC-section tipped the scales towards unnecessaryC-sections, costs up to Rmb11,000 and only takes up about 30 advocacybydetermined mothers likeWan could help minutes of the doctor’s time, providing amuchmore makereforms stick. “You have to inform yourself,” attractive revenue stream. Surgeries also yield a she says. “If the doctors see thatyou know whatyou larger hongbao (a giftpacket) from grateful families. are talking about, theyrespectyou and give you the Unscrupulous doctors can pad out revenues further by information you need.” making quicker (but harder to heal) vertical incisions, charging per suture to close the wound or adding extra Additional reporting by Luna Lin fees to remove gauze or stitches. In the 1980s, hospital births were the privilegeof China’surban citizens. Women in rural areas had their 1. babies at home and went to hospital for abortions or sterilisations after out-of-plan pregnancies. But by the 2000s, as migration to cities accelerated, the vast majority of Chinese women gave birth in hospital. Itisno coincidence C-section rates rose steeply at the same time. Therelaxation of the one-child policyhas revealed adisturbing downside to entrusting the future of the nation to the knives of surgeons in ahurry. Unofficial statistics for Beijing show arateofcomplications in pregnancies after C-sections of about 10 per cent. “Families, mothers, doctors all need to think differently,” says Dr Pang, who co-authored the 2008 study in TheLancetmedical journal thatdetailed, for the firsttime, the extent of China’sC-section problem. With the protection of along career at the WHO —and the blessing of the health ministry—she released it to the statetelevision broadcaster,triggering anational discussion of the problem. Newpublic messaging in favour of natural birth has found areceptive audience at Beijing’s main maternity hospital, where up to 1,500 babies are born each month. Heavily pregnant women stream through the doors. One dayinMay,everyexpectant mother who stopped for a chatagreed she would prefer anatural birth —aswitch in attitudes from justafew years ago. But altering public opinion is one thing; changing hospital procedure is another.InChina, as in the US, institutional factors such as doctors’ paystructure and hospital protocols keep C-section rates high. In biggercities, epidurals, known in Chinese as “no pain”births, now rival C-sections in popularity(and revenue potential). Dr Pang believes this is simply trading one interventionistapproach for another: “Conditions are different here. We don’t have enough anaesthesiologists.”For thatmatter,she thinks VBACs are also too riskytobecarried out widely in China, given the need for quick surgeryand ample blood supply if labour goes wrong. In hospitals in rural areas, where mostfamilies cannot afford C-sections, women are encouraged to walk around

22 |FT.COM/BIRTH Mortality rates in China In theUS, ‘C’ stands for 27 convenience maternal deaths per 100,000 livebirths

Caesareansections areamong the most frequently performed operations in the US.Asthe rate plateaus from its peak of 32.9 percent of births in 2009,medical researchersand health practitionersare working to reduce 11 the number of surgical deliveries. deaths of children One movement is trying to change the guidelinesthat under fiveper define howchildbirthishandled forlow-risk patients. 1,000 livebirths “Weknowwomen who areadmittedinearly labour are morelikely to have acaesareanand routine interventions, even if not clinically necessary,”saysHollySmith, anurse 2. practitioner and co-author of newguidelinesfromthe California Maternal Quality Care Collaborative(CMQCC) aimed at reducing this form of surgical delivery. Delaying labour is one of severalsuggested tactics to reduce caesareans. “There is alittlebit of denial that [caesareandelivery] is majorsurgeryand that it posesalot of problems,”saysCarol Sakala of the National Partnership forWomen &Families. Along with the CMQCC and other maternity caregroups in the countryshe wantstoimprove the quality of carefor mothersand newborn. The rate of caesareanbirthsinthe US has ticked up steadily since the late1990s. Of particular concern to manymedical professionals is the “overuse”ofthe procedureamong patients who might otherwise be suited to avaginal birth. Thereare severallife-saving reasons whydoctors in theUSturn to caesareans —for example,ifababyispoorly positioned or if the baby’s heartratechanges. The reasons on the partofthe mother range from conditions such as diabetes or obesity to complications with the placenta. In 2014,the American CongressofObstetricians and Gynecologists and the Society forMaternal-Fetal Medicine issued ajoint reportraising concerns overthe increase in the number of caesareanbirthswithout evidence of improvedmortality rates. While factorssuch as arising maternal age might explainthe increase,manybelieve the relativeefficiencythatcaesareandeliveriesallow is responsible.Doctors canplan foramuch shorterdelivery than through natural labour.Some researchindicates obstetricians opt to perform caesareans to help prevent malpractice suits forserious birth injuries. Butcaesareandeliveriescarry the risk of complications, such as infection, of major surgery, along with longer recovery timesthan most vaginal births. Newborns delivered by caesareanare at risk of impaired respiratory function. Caesareandeliveriesinthe US arealso some 50 per cent moreexpensivethanvaginal births. “It’smuch moreconvenient to say, ‘Well, youknow, it’s getting to be my dinner time and my family time.Labour is not progressing very fast. I’ll just do the caesarean now’,” says Sakala. Vaginal birth, in contrast, “requires alot morepatience and resourcesand inconvenience on the system”. Aimee Keane

FT.COM/BIRTH | 23 BRAZIL ZIKA VIRUS Lives under strain

As evidence growsofalinkbetween Zika and birthdefects,poorercommunities areparticularly vulnerable.BySamantha Pearson in Recife

nNovember 12 2015, at ahospital in Brazil’s north-eastern cityofRecife, Maria Eduarda was about to be born. Hermother lived on the streetand wanted nothing to do with the baby — Oshe had already had seven children and had abandoned them all. Herfather was an alcoholic and incapable of looking after himself,but he had asister, Miriam, who had agreed to care for the child. Miriam Pereiraand her 18-year-old daughter-in-law, Cleane Stefani, were at the hospital, waiting to collectthe little girl. They had already settled on the name. It was not until after Maria Eduarda had been delivered thatStefani and Pereirarealised justhow difficult her life —and theirs —would become. Doctors measured the circumference of her head. At 26cm it was has several seizures aday.She is one of an estimated about 6cm less than the minimum for ahealthychild, 2,000 babies in Brazil born over the pastyear with signalling asevere case of the birth defectmicrocephaly. microcephaly —acongenital condition where the baby’s

“Wehavenoideaifshe’llever walk or even talk,” says brain does not develop correctly during gestation, S

Stefani, as she cradles the 11-month-old baby in her arms leading to an abnormally small head. Mounting evidence GE

in the family’s cramped, makeshifthome in afavelaby over recent months has shown thatthe Zika virus is at IMA

ahighwayinOlinda, on the outskirts of Recife. Thetwo leastpartly responsible for nearly all of the recent cases TY ET

women do have an idea of whatcaused the birth defect, of whatisotherwisearare condition. /G however: Maria Eduarda’smother caught the mosquito- While researchers develop avaccine againstthe OTO

borne Zika virus about three months into her pregnancy, virus, which is not expected to become widely available PH

according to Stefani. in Brazil for another couple of years, scientists are UR As well as needing atubetoingestliquids, Maria struggling to understand Zika’smysterious effects. :N TO Eduarda has difficultybreathing and moving, and Infections have been reported in 72 countries since 2007, PHO

24 |FT.COM/BIRTH Daily challenges according to the World Health Organisation, yetthe degree of neurological damage.“Often theyshow signs Cleane Stefani with number of cases of microcephaly linked to the disease of being hyperexcited, with some difficultyorlack Maria Eduarda, whose has been much higher in Brazil than in other Zika-hit of co-ordination when it comes to breastfeeding or mother caughtthe Zikavirus during countries such as neighbouring Colombia. feeding themselves,”she says. pregnancy While researchers are investigating factors other Health workers now fear apossible second surgeof than Zika thatmay be behind the sharp rise in microcephaly in southern cities such as São Paulo over microcephaly in Brazil, theyare also looking into the coming hot summer months. While researchers other possible effects of Zika on pregnant mothers and believe manywomen in Brazil’s north-eastwill already babies. Tânia Saad, aneurologistatthe Fernandes have been infected with Zika by now,thus gaining FigueiraNational Institute for the Health of Women, immunitytothe virus, São Paulo’s expectant mothers Children and Adolescents in Rio de Janeiro, says the maybemore vulnerable, having not been exposed to the children of mothers infected with Zika who did not disease before falling pregnant. develop microcephaly have nevertheless shown some “The trend is thatthe biggest outbreaks will occur

FT.COM/BIRTH | 25 BRAZIL ZIKA VIRUS

‘Weneed to be quicker and betteratresearching lesser- knowninfectiousagentsbefore they cause epidemics’ in states where there have so far only been afew cases,” says Pedro Vasconcelos, director of the EvandroChagas public health institute in the northern stateofPará. “Meanwhile, in those states thathavealready been badly affected, there are likely to be [no new] Zika infections or only asmall number of cases.” Such forecasts are little comforttoStefani and Pereira, or to the thousands of families having to care for achild with microcephaly.Stefani, who dropped out of school when Maria Eduarda was born, looks after the baby during the day, while Pereira, who has had to quit her cleaning job, takes the “night shift”,she explains. Almosteveryday,the women have to catch twobuses to attend seemingly endless hospital appointments in Recife, often returning late at night, theysay.Apart from asmall government disabilityallowance, Stefani and Pereirarely on the moneythatStefani’shusband — Pereira’sson —earns fitting car radios. Thebiggest expense is lactose-free milk powder, 1. Stefani says, pointing to atin thatcosts R$120 ($38), Cleane Stefani, left, equivalent to about 15 per cent of the monthly minimum at home with Maria Eduarda and Miriam wage. Maria Eduarda needs acouple of tins aweek, Pereira Stefani says. “The government is meant to give thattous 2. for free, but for the pastthree months theyhaven’t had Mothershold their anyavailable,”she explains over the noise of apopular infants, all born with soap operablaring from the television in the living room. microcephaly,after visiting arehabilitation Zika has had adevastating effectonBrazil’s poorer clinic in Recife communities. Themosquitos thattransmit the virus thrive 2. in the stagnant water abundant in favelas such as the one where Stefani and Pereiralive, which lack adequate plumbing and sanitation. Theoutbreak has also come just as unemployment is surging during Brazil’s recession and Mortality rates Similarly,the Ebola outbreak thatbegan at the end government health budgetsare under tremendous strain. in Brazil of 2013 also hit Africa’spoorestcommunities the hardest. MeganLees-McCowan, head of programmes in westAfricafor StreetChild, aUKcharity, estimates that12,000 children lostone or both caregivers to the virus. “Orphaned children found themselves leading the household; teenagegirls became pregnant as theyexchanged sexfor food to 44 survive; and poverty increased for already poor families maternal deaths per who found themselves caring for the additional children 100,000 livebirths of deceased relatives,”she says.

Outbreaks such as Zika and Ebola should serve as a N

reminder for governments thatitmakes more financial RSO

sense to research the effects of mosquito-borne diseases EA before theycause widespread and expensive health AP crises, says Vasconcelos. “Weneed to be quicker and 16 better at researching lesser-known infectious agents MANTH SA

deaths of children before theycause epidemics,”hesays. S;

under fiveper Back in Olinda, Stefani doubts she will have time to GE 1,000 livebirths finish her studies or go to work as Maria Eduarda grows MA YI

up. While Pereirawill officially adopt the child, Stefani TT

cares for the baby girl as if she were her own. “I didn’t GE S:

really know whatIwanted to do as ajob anyway,” TO 1. Stefani says. “Now it doesn’t matter.” PHO

26 |FT.COM/BIRTH INNOVATORS ARGENTINA From bottles to births

Asimplebut effective invention by an Argentine mechanic couldhelp ease complicatedbirths. By Andrew Jack

Theproject Becton Dickinson, aUSmedical technology company, is developing asimple device to ease complicated births around the world, in partnership with its Argentine inventor and the World Health Organisation.

Theneed Aquarter of all neonatal mortality and nearly half of stillbirths occur during labour and child delivery, with an estimated 9 per cent of all maternal deaths caused by prolonged or obstructed labour.The current use of forceps and vacuum extractorshas been unchanged fordecades.Both are complex, carryrisksfor mother and babyand require healthcareworkerswith alevel of training not alwaysavailable in low- and middle-income countries. The alternativeis caesareansection, but this requires access to surgical facilitiesand increasesthe cost and risk of infection.

Howitworks TheOdón device wasconceived by Jorge Odón, acar mechanic who wasinspired by asimple method to remove acorkfromabottle using aplasticbag. Becton Dickinson is spending $20mdeveloping, testingand scaling it foruse in childbirth. The basic design consists of an applicator to locate the baby’sheadand aplastic sleeve with apump and inflatable collar to deliver the baby. The plan is to launch it in 2019.

Theimpact Afirst testing of the device on 48 women in Argentina showedverypromising results, and alarger-scale clinical trial is set to begin in South Africa this monthahead of clinical trials in Europe andIndia in 2017.With plans formodest pricing in lower-income countries, cross-subsidised by higher pricesinricher ones, it offerspotential forimproved, affordable and accessible birth assistance.

What is needed next? • Regulatorybacking if the device is shown to be safeand effective, so that it is rapidly approvedinmanydifferent countrieswithout imposing additional requirement and delays that slowits uptake. • International funding from donorsorinvestorstohelp order,manufactureand distributewidely, so it can achieve economiesofscale and permit across-subsidy to make it affordable to thepoor. • “Last mile”supporttointegratethe device with stateand non-governmental organisations, to supply,train and provide widespreadaccess to women even in the poorestand most remoteareas.

Want to help? Email: [email protected]

FT.COM/BIRTH | 27 POLAND BREASTFEEDING Notin public, please

Social conservatism andalack of soundadvicefromhealthcarestaff make many nursingmothers in Poland feel like pariahs

By ZosiaWasik in Warsaw Photographs by PiotrMalecki

uzia Jesionowska, MartaAndreasik and Ania Niziolek all agree theyhavebeenlucky. The young mothers have breastfed their babies all over Warsawwithout receiving any negative comments. They also realise their Zexperiences are not the rule in Poland.Before Jesionowska became amother she did not understand whyawoman would breastfeed in public. Now, she says, she feeds seven-month-old Mikolaj anywhere. Andreasik has even breastfed her six-month-old, Amelia, in a church. Niziolek’sson, Ignacy, is 21 months old and eats solid food but she still breastfeeds him occasionally.She covers him with ascarftoavoid attention. In Poland, breastfeeding in public is acontroversial topic. Liwia Malkowska made headlines in August when she took her six-month-old daughter to a restaurant in Sopot, aseaside resortonthe Baltic. While youwait When the infant began to cryshe attempted to Marta Andreasik breastfeed her at the table. Before she had unbuttoned breastfeeds her her blouse, awaiter told her to move to the toilets. six-month-old daughter Amelia In response, Krzysztof Smiszek, head of the Polish at abus stop in Society of Anti-Discrimination Law, is suing the Warsaw

28 |FT.COM/BIRTH

POLAND BREASTFEEDING

1. Zuzia Jesionowska with her son Mikolaj, aged sevenmonths, inWarsaw 2. Feeding time for Mikolaj at acafé 3. Polish womenmarch to protestproposed anti-abortion legislation

1.

30 |FT.COM/BIRTH ‘Itiseasiertoget a formulathantoget good advice about lactation from amidwife’

restaurant for discrimination. It is an unprecedented case in Poland and one of veryfew thathavebeen made across the EU.The society has also filed arequesttoa Polish judgetodirectthe question to the European Court of Justice. If the ECJ rules thatstopping mothers from breastfeeding in public is discriminatoryand thus illegal, it is likely to setaprecedent forall EU member states. Malkowska’scase has triggered apublic debate in Poland. According to Institute of Media Monitoring records, public breastfeeding-related content was viewed 20m times and provoked more than 100,000 online interactions in the week after the incident. Themajority of comments were in supportofMalkowska, but there were also critics, likeMarek Migalski, aformer MEP, who compared breastfeeding to “farting”. 2. Smiszek says he has received calls from people angry at whattheysee as his promotion of “moral laxity”.But, he says, “some people also said[thiscase] is only the tip Mortality rates lot to do,”saysPietrusiewicz. Normalising breastfeeding of the iceberg and thatwomen are being maltreated in in Poland in public is one of the foundation’s goals. Pietrusiewicz shopping malls, restaurants. We touched an issue that has no explanation for whythe debate on the subjectis had been swept under the carpet.” so heated in Poland. “Isitbecausebreastfeeding is very In October,Polish women forced another issue into intimate?Or, in aconservative mentality, awoman the limelight. Tens of thousands of them marched on should sit at home with her baby? Or maybe because it is the streets, dressed in black, to protestagainstaban on connected to aphysiological act?” she asks. abortions proposed by the ruling conservative Lawand 3 Agata Aleksandrowicz, who writes apopular Polish Justice (PiS) party.The demonstrations prompted the blog about breastfeeding, thinks thatmothers who nurse maternal deaths per government to pull back from its plan, at leastfor now. 100,000 livebirths openly are not socially accepted because there are simply Progress in other areas of childbirth and care has been not verymanyofthem: “These women are not visible patchy, says Joanna Pietrusiewicz, head of the in public spaces, so breastfeeding becomes averyrare Foundation for Childbirth with Dignity, aPolish phenomenon, something unwanted,”she says. non-governmental organisation thatseeks to protectthe TheWorld Health Organisation recommends babies rights of pregnant women and mothers. Thefoundation are exclusively breastfed up to six months of age, with celebrates its 20th anniversarythis year and its experts 5 continued, complementarybreastfeeding for another two saythatalthough there has been some progress in deaths of children years or more. This helps mothers by speeding up their increasing the safety of medical procedures during under fiveper recoveryafter childbirth, and babies too, as breastmilk childbirth, it is not enough. “There is another issue: a 1,000 livebirths contains all the essential nutrients for their development. human approach to perinatal care. Here Poland still has a In Poland, anywoman who follows these guidelines and is unable to breastfeed openly would find her lifestyle severely restricted. 3. Almost99per cent of Polish mothers want to breastfeed their babies when theyleave hospital. But mostsoon give up —only 14 per cent breastfeed exclusively until their baby is six months old, according to research by Urszula Bernatowicz-Lojko, aneonatologist. “Whatever issue we look at —breastfeeding in public, the expertise of medical staff, the knowledgeofmothers, the advertisement of formula milk —the topic has been neglected and no one has ever doneenough to fix it,”says Aleksandrowicz. Theproblems begin in maternitywards, S

GE where everythird newborn is fattened with formula,

IMA according to areportbythe Supreme Audit Office.

TY Producers sell modified milk cheaply,oreven give it ET away,which means babies quickly getused to bottles. :G

TO Midwives often do not have up-to-date knowledge on lactation, says Pietrusiewicz. “Itiseasier to get PHO

FT.COM/BIRTH | 31 POLAND BREASTFEEDING

‘Women saytheyfeel embarrassed; they getasense

that breastfeedingisnot Home comforts Ania Niziolek with welcomeattheircompany’ her son Ignacy, aged 21 months, at her flat in Warsaw aformula than good lactation advice from amidwife.” Paediatricians and gynaecologists —the firstspecialists women see after childbirth —are similarly shorton proper advice: 45 per cent of doctors recommend women experiencing problems with lactation to bottle- feed instead of breastfeeding. Only 7per cent suggest an appointment with alactation expert,according to areportfrom Nutropharma, acompanythatproduces Femilakter,asupplement for breastfeeding mothers. Another problem is the advertising of formulas. Poland has committed to comply with the recommendations of the WHO’sInternational Code of Marketing of Breast- milk Substitutes, which restricts the marketing of such substitutes to ensure thatmothers arenot discouraged from breastfeeding. It also includes aban on product sampling and advertising, but since the code is not binding, Poland has implemented only afew of its recommendations. Asaresult, formula is advertised in the media next to articles on breastfeeding or healthy nutrition. In shops, processed baby food is availablefor four-month-old infants. Thetop hits in aGoogle search of “breastfeeding”inPoland are links to Pampers nappies and campaigns organised by formula producers Nutricia and Nestlé. In the UK,bycomparison, the top twolinks are to National Health Service webpages on the benefits of early and continued breastfeeding. Breastfeeding is even more problematic for working mothers. Under the Polish labour code, nursing mothers can taketwo 30-minute breaks aday to express breastmilk. “Wedonot know how [thatlaw] is implemented,”saysPietrusiewicz of the Foundation for Childbirth with Dignity. “Weget information from women who saytheyfeelembarrassed; theyget asense thatbreastfeeding is not welcome at their company.” Workplaces do not usually provide women with privateplaces to nurse —halfofwomen claim no space is made available in which theycan express breastmilk. Thelackofsuchfacilities, and the negative attitudes of employers and colleagues, force 74 per cent of women to stop breastfeeding prematurely,according to the Nutropharma report. Newinitiatives aim to empower women to breastfeed in public. TheLand of Milk and Love foundation, for instance, creates comfortable corners for mothers in museums. “A drop bores through rock. In this case, amilk drop,”saysPatrycja Soltysik, the head of the foundation, who was herself rebuked while breastfeeding her son in public —anepisode thatshe says spurred her to takeaction. Pietrusiewicz says public promotion of breastfeeding is crucial to give mothers knowledgeand choice. “We can make100 per cent of women breastfeed, but that is not whatitisall about,”she says. “Itisabout women being relaxed, calm, happy and able to experience their maternitythe waytheyfeelitshould be.”

32 |FT.COM/BIRTH COMMENT OONACAMPBELL

journal estimated that29per cent of maternal deaths could be averted by giving women access to family planning when needed. But women, families and societies everywhere want and need to ensure thatwomen and their babies survive childbirth too, justastheydoinrich countries. Drugs are essential but, even with them, simple solutions elude us. Haemorrhage, the leading cause of maternal death worldwide, can be prevented and treated using uterotonics such as oxytocin. Given preventatively, theycan halve the risk of haemorrhageand should be available to all women who give birth, as acost-effective intervention. Thepharmaceuticals industryisworking on producing forms thatare easier to deliver to women, such as uterotonics thatdonot requirerefrigeration. Technical and advocacywork is also under wayto ensure these kinds of crucial medicines are on national essential drug lists, thatsupply chains function correctly to makethem available at health facilities everywhere andthathealth workers know whattodowith them. But while uterotonics can prevent, reduce and treat haemorrhage, and have other useful applications, theycan be misused —tounnecessarily induce labour early,for example, or to augment and strengthen contractions without good reason. Thesame drugs, then, can both help and harm women and their babies. Some women gettoo little, too late; others too much, too soon. Without informed, supervised and caring health workers, an apparently simple solution becomes a complexproblem. ‘These arenot We need to look beyond materials to management. Good-qualitycare and effective interventions do not centre on drugs or tools, but instead require systems to “wickedproblems” work: facilities, healthcare providers, emergencymedical transport, governance, information and financing. Countries such as Cambodia are tackling this issue withoutsolutions’ on multiple fronts. As aresult, maternal mortalityhas dropped from 1,020 per 100,000 live births in 1990 to 161 in 2015. Challenges remain: in common with other Preventing maternal deaths requiresmorethan low- and middle-income nations, ambulance numbers just drugsand tools, says Oona Campbell in the countryare increasing rapidly,but alack of coordination compromises their impact. Cambodia is working to improve links between facilities, help health centre and hospital staffto deep, dark and continuous stream of reviewreferrals, discuss improvements, standardise mortality” is how William Farr,working in referral guidelines and promote provincial-level the General Register Office in England in obstetric care hotlines. These effortsshould help the the 1870s, described deaths in childbirth. countrycontinue its progress in terms of maternal health Yetsince then, particularly from the 1930s and making sure women and babies are transported to Aonwards, maternal deaths in the UK have the care theyneed. Scaling up such systems will benefit plummeted, to become almostinvisible todayatnine not justwomen and babies but also improve emergency deaths per 100,000 live births. Howdid it happen and care for everyone who needs it. whatworked to bring this about? Can we transfer the Ultimately,interventions to guarantee thatwomen lessons to countries such as Chad, where women face a and babies survive this riskiestperiod need to function risk of dying thatismore than 180 times higher than in in complexways. Healthywomen, wanted pregnancies, high-income countries? caring and skilled healthcare providers and engaged Thedream of the quick fix —the intervention, the and problem-solving policy-makers and communities tool, the drug, the one thing thatwill stop mothers are the ultimate effective interventions. These are not dying —endures.The closestwehavecome to one are “wicked problems” without solutions. They are rather drugs and devices thathelp women to avoid giving birth: hard problems thatrequire capacity, care, integrityand contraceptives, emergencycontraceptives, abortion by thoughtfulness. That success is achievable. medication and other safe methods, thatcan prevent unwanted and mistimed births. Oona Campbell is professor of epidemiology and They are effective and easy to distribute even to rural reproductive health at the London School of Hygiene areas. A2012study published in TheLancetmedical &Tropical Medicine

FT.COM/BIRTH | 33 EL SALVADOR ABORTION

Denied a pardon Mirna Ramírez received a 12½- year sentence for attempted murder after giving birth prematurely in a latrine

34 |FT.COM/BIRTH ‘An aggressive, punitive attack on women… a witch-hunt’

Rights groups and even the UN have called El Salvador’s draconian anti-abortion laws an ‘injustice’, with women jailed for murder and doctors working in a culture of suspicion

By Jude Webber in San Salvador Photographs by Bénédicte Desrus

FT.COM/BIRTH | 35 EL SALVADOR ABORTION

irna Ramírez’sdream was amodestone: to raise acouple of children. She watched ‘Where is thecriminal her firstchild, aboy,die at four months of abrain abnormality.Worriedthe same intentinmiscarriage? thingmight happen again, she kept her Msecond pregnancyquiet. But amonth Youmight as well be before she was due to give birth, she went into labour prematurely and her daughter fell into alatrine. The judged forsneezing’ baby survived, but Ramírez was arrested for attempted murder and sentenced to 12-and-a-half years in jail. The48-year-old Salvadoran blinks back tears as she delivered her baby alone in an unlit room in her describes seeing photographs of her daughter learning to employer’s house. Thebaby died. Hours later,still walk, and birthdaycelebrations she could never attend. bleeding profusely,she was taken to hospital, where she “Mylife has been afailure,”she says. wokeuphandcuffed to the bed. Ramírez was convicted under anti-abortion laws so Vásquez was pardoned lastyear,after serving seven draconian thatnot only seeking to terminate apregnancy years of her 30-year sentence for aggravated murder.The but even suffering amiscarriageorcomplicated ruling recognised “she was convicted on the basis of mere premature birth can putawoman behind bars for as presumptions” and the sentence was “disproportionate, long as 40 years under charges of aggravated murder. excessive, severe and unjust” —especially since the Pro-choice activists sayElSalvador’s enforcement of baby’s cause of death had never been established. anti-abortion legislation is harsh even among countries Herrelease followed acampaign to free 17 women where the lawcomes down emphatically against serving long sentences, spearheaded by Morena Herrera, terminations. It has created aculture of suspicion, they El Salvador’s leading advocate for abortion lawreform. say, in which women are presumed guiltyand reported Arguing thatthe women are victims rather than by the veryhealth professionals theyturn to for help. criminals, activists filed simultaneously for pardons for Theatmosphere in the public health service has the entire group in April 2014,but only Vásquez’ssuit become pernicious. Doctors and stafffear thatfailure to was accepted. Ramírez, who had been allowed in the reportasuspicious case will costthem their jobs or have later years of her prison term to work outside the jail them charged with complicity. Many statehospitals are and to visit her family during the day, was freed for good no longer asanctuarybut the lastplace awoman who behaviour.Apardon was denied on the grounds that has tried to abortorsuffered an obstetric emergencycan she had almostfinished her sentence. Theother 15 suits go,even if she is bleeding so badly she could die. were rejected and activists are still fighting to have these Activists put the number of women jailed on abortion- sentences commuted or reduced. related charges at 49 —some for aprocedure that Even if appeals succeed, victorymay be short-lived. millions of women worldwide consider their right, others In May, María Teresa Rivera, who had served four following medical emergencies or miscarriage(the term years of a40-year sentence, was freed after the judge 1. in Spanish is “spontaneous abortion”). Other estimates Salvadoreanwomen acknowledged errors in the case, but prosecutors are now give double thatnumber of women imprisoned. rally to demand the appealing againstthe ruling. “Where is the criminal intent in miscarriage?”asks decriminalisation of Sitting on the plant-filled patio of her house, Herrera Dennis Muñoz, alawyer working with rights groups to abortion in frontofthe drinks black coffee and sucks on cigarette after cigarette. LegislativeAssembly free women in prison on abortion charges in Central this September Aformer guerrilla fighter in El Salvador’s civil war America’ssmallestcountry. In asociety thatisreeling 2. between 1980 and 1992 and amother of four daughters, from violence between brutal streetgangs, the harshness Morena Herrera, a she looks unshockable. But she shakes her head of the punishment seems particularly unjusttoMuñoz. former Marxist guerrilla, incredulously as she recalls the storyofamiddle-class “You might as well be judged for sneezing,”hesays. nowdirector of the friend who was so desperatefor help after her daughter San Salvador Feminist Collectiveand pro- tried to abortand was bleeding profusely thatshe was ntil about 20 years ago, El Salvador permitted abortion activist willing to takeher to apublic hospital. abortion if the woman’s life was at risk, if foetal Umalformation made the baby’s life unviable or 1. if the pregnancywas the result of rape. Despite the influence of the Catholic Church, which teaches that life begins at conception, privateclinics offeredsemi- clandestine abortions —taboo but quietly tolerated, expensive but not exorbitant. But following lobbying by anti-abortion groups, a newpenal code took effectin1998, outlawing abortion outright. Chile, Honduras and Nicaragua are among

Latin American countries with similar bans, but El S

Salvador is unique in instituting whatDee Redwine, GE

head of the Latin American programme at the Planned IMA Parenthood Federation of America, aUSabortion TY ET

provider,calls “an aggressive, punitive attack on /G women… awitch-hunt is averygood wayofputting it”. FP :A

Carmen Vásquez Aldana, adomestic worker who TO became pregnant after being raped at the ageof17, PHO

36 |FT.COM/BIRTH 2.

“I’drather you were arrested than dead,”she recounts Mortality rates merican pro-choice campaigners are watching the friend telling her daughter.“Ican getyou out of in El Salvador the situation in El Salvador closely,asabortion jail, but not out of the cemetery.”The young woman Arights, enshrined under the landmark Roe vWade eventually escaped punishment because she was taken case in 1973, are being eroded in some US states. “Since to aprivateclinic. 2011, we have seen more than 334 abortion restrictions Activists sayeach of the 17 women is guiltyofnothing enacted in 32 states —that’shuge,”saysElizabeth Nash, more than going into labour prematurely,without a senior stateissues manager at the Guttmacher Institute, midwife or doctor present, and often without having aWashington-based non-profit organisation thatfocuses had anyantenatal check-ups thatcould have detected 54 on sexual and reproductive health. gestational problems. They have to prove their innocence. maternal deaths per Theresult of El Salvador’s ban is agaping social Ramírez’sbabywas born at eight months. “I didn’t 100,000 livebirths divide between those who can afford an abortion in a touch her.She justcame out,”she says. After helping privateclinicwhere doctors feel no pressure to report to rescue the baby,who was alive, aneighbour called their patients, and those forced to rely on the flourishing the police. “Theysaid Ihad her and threwher in [the back-streetabortion industry. latrine],”saysRamírez. When she was taken to hospital, Misoprostol, an abortion-inducing drug, is readily it was in handcuffs in apolice car —the startofa available on the black market.The less well-offresort legal odysseyofmore than adozen years thatended in 17 to caustic soda tablets or coathangers, doctors and October 2014 when the Supreme Courtapprovedher deaths of children activists say. With no medical follow-up, the third of release. By thattime, she had less than amonth of her under fiveper El Salvador’s 6m peoplewho live in poverty have the original sentence left to serve. 1,000 livebirths fewestoptions when things go wrong. In astatement, the UN applauded Vásquez’srelease, Camila —whose name has been changed to protect saying it “reverses an appallingly unfair sentence… her identity—feels she gotoff lightly.Now 24,she was but there are manymore women imprisoned 15 when she found out she was pregnant by her 16-year- on similar charges”.Itistime for El Salvador’s old boyfriend. “Helookedonthe internet, went to San government to reviewthe abortion ban “to end such Salvador and bought twopills for $80,”she says. “I don’t injustices”,the statement urged. El Salvador’s justice know whattheywere.”Withinhours of taking the ministrywould not comment. dose, she was haemorrhaging. Unable to confide in

FT.COM/BIRTH | 37 EL SALVADOR ABORTION

1. Delmi Ordóñez, who spent 11 months in prison formurder beforeher case was dismissed, with her three-year-old son 2. Morena Herrera with Jorge Menjívar, aspokesman for CitizenGroup forthe Decriminalisation of Abortion 3. SaraGarcía Gross and lawyer Dennis Muñoz on aSan Salvador radio programme called ‘Fromthe Hospital to thePrison’

1.

38 |FT.COM/BIRTH ‘Theydecided it was an abortion—no one knew,soImusthave covereditup’

countries overall —although supportamong young people was growing. It took the dramatic case of Beatriz in 2013 to thrustthe issue into the spotlight. The22-year-old, identified only by thatname, wasdenied an abortion by El Salvador’s Supreme Court, despite the factthat she suffered from lupus and doctors had warned the pregnancywas putting her life at risk. Thecourtrefused on the basis thatitwas upholding the constitutional right to life from conception and that awoman’s human rights could not takeprecedence over those of her unborn child. That Beatriz’sbabyalso had adefectcalled anencephaly,inwhich parts of the brain do not develop, made no difference. Babies with the condition rarely survive more than afew hours. TheInter-American CourtofHuman Rights urged the government to save Beatriz’slife. “Inthe end, she started to have contractions and theyhad to perform a 2. caesarean,”Herrerarecalls. Thebaby died within hours. Beatriz’sordeal prompted María Isabel Rodríguez, her mother,who still does not know she had an abortion then El Salvador’s health minister,tocallfor achangeto —“she’d kill me” —she went to afriend’s house. “When I the law. She has called it a“crime” and an “injustice”. couldn’t stand it anymore, Iwent to hospital.” InOctober,Lorena Peña, president of El Salvador’s There she was grilled about whatshe had taken and Congress from the ruling FMLN party,referred to who had helped her,but in the end, her agesaved her Beatriz’scase when she introduced abill to decriminalise frombeing reported by the hospital staff. Then, twoyears abortion if the mother’s life is at risk, if the pregnancy ago, Camila was raped by her father,and the nightmare is the result of rape, if the baby’s life is not viable or in loomed again. In the end, she did not become pregnant. the case of under-agegirls. “Here we are not the holy “If Ihad been, my life would have been over,” she says. inquisition —this is the Salvadoran assembly in the 21st “[Abortion] is more penalised than anycrime,”says century,”Peña said. Herproposed amendment to the Delmi Ordóñez, who, like Ramírez, gave birth in alatrine. penal code would restore aright enshrined in Salvadoran Doctors saysome women deliver into toilets because lawfromthe late 19th centuryuntil 1997,she said. of cervical incompetence. Bathed in blood, Ordóñez But Herreraexpects the bill to run into tough fainted after the birth, she says, waking up in hospital opposition from the conservative Arena party.She to find doctors demanding to know whatshe had done has been called an apologistfor whatisconsidered with her child. Because she had been using injected contraceptives, Ordóñez had not even known she was 3. pregnant, although she already had ason.“They decided it was an abortion —noone knew,soImust have covered it up.”The baby,which Ordóñez never saw, was found dead in the latrine by firemen. Ablow to its head was proof enough for the authorities thatthis was murder. Once Ordóñez was out of danger,she was arrested, and spent the next 11 months in prison. Thecase against her was finally dismissed, but she still feels consumed by guilt, even five years after her release. “I practically felt I’dkilled him because Ididn’t takeproper care of myself. Ididn’t realise, Ididn’t go to the doctor,” she says.

he abortion ban has widespread supportinEl Salvador,where machismo and religious faith run Tdeep. Asurveybythe Latin American Observatory of Drug Policyand Public Opinion, athink-tank Asuntos del Sur,found Salvadoran supportfor abortion to be the lowestinthe region —about half the level of surveyed

FT.COM/BIRTH | 39 EL SALVADOR ABORTION

by manySalvadorans to be aheinous crime. Even in the Behind these bars rights and obligations as adoctor.Myjob is to provide Ilopangowomen’s jail —where mostofthose convicted Ilopango women’s medical help. I’mnot apoliceman.” on abortion charges have been incarcerated —sympathy prison on the outskirts This is the same point made by Muñoz, the lawyer. of San Salvador where can be in shortsupply.Ramírez and Ordóñez saythat women have been Talking fastand thumbing through his three-inch- during their time in prison theykept quietfor fear of held on abortion- thick copy of El Salvador’s Criminal Procedural Code, being branded “baby killers”. related charges he points to the relevant articles that, he says, protect doctors —despite arequirement thathospitals report osa (her name has been changed), agynaecologist injuries sustained as the result of asuspected crime. who quit the public health service, says that“many One of his defendants, Carmelina Pérez, aHonduran, Rtimes” she refused to reportsuspected abortions was given a30-year prison sentence in 2014 after the and falsified her patients’ medical reports. Eventually, doctor who reported her to the police gave evidence in sheswitched to aprivateclinic,helping twotofour court. Later thatyear,inanappeal,Muñoz successfully women amonth to abort, provided theywere referred argued the doctor should have refused to testifyunder through people she knew. “If someone comes to me that article 205, which establishes thatpatient confidentiality Idon’t know,Ican’t help them. It makes me mad, but requires thatdoctors not testifyagainsttheir patients. Ican’t expose myself [to the risk] either,” she says — “This is now alegal precedent,”hesays, triumphantly. potentially six to 12 years in prison and the permanent But Muñoz’scelebrations have been short-lived. revocation of her physician’s licence. Although Pérez was released and returned to Honduras, “You don’t know who you can trust. It’s veryriskyand I the courtorder freeing herhas itself since been revoked. don’t think that’sgoing to change,”saysValentina (also Ajudgehas accepted an appeal by prosecutors to reopen not her real name). Despite being ahealth professional the case. El Salvador mayhavetoissue an international herself —she is adentist —she did not know where to arrestwarrant to gether back before ajudge. turnafter suffering complications from taking misoprostol. Herreracompares the case to thatofSonia Tábora, who She was referred to Rosa. Privateabortions can costas was jailed in 2005 for 30 years after giving birth while much as $3,500 and Rosa says she has colleagues who working in acoffee field. According to activists, the baby perform them as asideline, with the proviso thatpatients was either born dead or died soon afterwards, and was do not know their names or see their faces. buried in the field; Tábora, bleeding, fainted. Hercase was Themost“absurd”thing, Rosa says, is she knows reviewed after seven and ahalf years and she was freed. thatintheorythe lawprotects her: it says doctors are But thatreviewwas struck down. Táboramustgoback in not required to breach patient confidentiality. Another the dock even though she now has another small child. safe-abortion practitioner nicknamed “Dr Help”, There is no trace of the tough guerrilla as Herrera who charges his patients between $100 and $1,000, contemplates whatcould happen next. “I justdon’t know depending on their abilitytopay,adds: “I know my whatI’lldoiftheyconvicther,” she says.

40 |FT.COM/BIRTH INNOVATORS KENYA Contracts forcare

Ascheme to providemedical equipmentacrossthe country. By Andrew Jack

Theproject An ambitious 10-year,Ks38bn ($375m) “turnkey”financing and deliverycontract between the government of Kenyaand five international companiestoprovide andmaintain medical equipment across the countryand train users.

Theneed In manypoorercountries, medical equipment to improve diagnosis and treatment is in scant supply.Evenwhereit has been purchased in the past, the absence of adequate staffing, training and maintenance means it frequently breaks down and is abandoned. The high up-front costs are abarrier to governments buying equipment and improving their services.

Howitworks TheKenyangovernment launched an international tender and contracted companiestosupplyand supportradiology, intensivecareunits, dialysis and surgical facilitiesinhospitals in all the country’s47districts. It has undertakentoprovide the basic infrastructure, whilethe companiessupply and ensure that their equipment is functioning 98 per cent of the time, receiving payments everyquarteriftheymeet these targets.

Theimpact The contract, forwhich negotiations began in 2014,is nowoperational, with facilitiesacross the country, while previously manyofthe serviceswereonly availableinone or twoplaces. Initial evidence suggests that it is functioning well, improving the reliability,speed,access and accuracyof servicestotackle ill health morerapidly and efficiently.Ithas also generated large numbersoflocal jobs, from healthcare workerstotechnicians, and triggered risk-sharing and funding between the providersand local financial institutions.

What is needed next? • Technical supportfor legal advice,insurance and finance for futureexpansion or replication. • Evaluation to establish clear baselinesand, overtime, measurethe widerimpact of the programme,including its effect on increased identification and demand forservices, and changesinoutcomesand cost. • Broader funding, including the introduction of healthcare expendituretoensuresufficient staff and facilitiestocope with the equipment and the referrals that result. • Newvendorstoextend the programme to other functions, including laboratoryequipment, neonatal and dental care, and laparoscopy. • OthercountriestofollowKenya’s pioneering model in Africa, adapting amodel moretypically found in richer nations.

Want to help? Email: [email protected]

FT.COM/BIRTH | 41 SIERRA LEONE MATERNAL MORTALITY

42 | FT.COM/BIRTH Life or death An ambulance heads off on a 20-mile journey to bring a teenage girl in labour to Moyamba government hospital

The slow road to progress

Sierra Leone is thought to have the world’s highest maternal death rate, but to address its myriad causes the government must first gain the trust of its people

By Finlay Young Photographs by Tom Pilston

FT.COM/BIRTH | 43 SIERRA LEONE MATERNAL MORTALITY

tisjustbefore 6pm when the call comes in to TomSwaray’s mobile phone. Thesun in Moyamba DistrictinSierraLeone’s Southern Province is well on its waytosetting. Theinformation he receives is scant. An unnamed pregnant girl —17, maybe 18 I—has been in labour for 12 hours. She is in atown called Rotifunk. “Not too far,” Swaray says, and calls for one of his ambulances. Forty-five minutes later the Toyota Land Cruiser pulls up next to the emptywhite tarpaulin tents thatwere originally pitched to treatEbola patients and are now the district’smedical centre. Thelight is fading as the driver, Michael Elie, sets offover the ferrous dirttofind anurse at Moyamba government hospital. He emerges with Jane Fatmata Kamara, pulled from her triagenight shift, and the twoset offinto the dark. Thegirl theyare going in search of became pregnant 1. in aplace where death often follows birth. SierraLeone is thought to have the highestrateofmaternal deaths of anycountryinthe world. Women here have an estimated Maternal mortality ratio one in 17 chance of dying from pregnancyorchild birth- Per100,000 livebirths related causes. To place this figure in historical context, UK parish records show better odds for English mothers in the early 1700s. 3000 Thesame maladies thatkilled those British women SierraLeone Other selected 300 years agoare killing women in SierraLeone and African countries 2500 across sub-Saharan Africa today: haemorrhage, sepsis, hypertensive disorders, illegal abortions, obstructed South Sudan labour.All can be treated successfully with basic 2000 interventions, as long as whatpublic health specialists call the “three delays” do not supervene: in seeking care, Liberia reaching care andreceiving care. 1500 That is whyElie and Kamaradrive at breakneck speed along the narrow,perilously veined, cratered road to Rotifunk. On the map it is only 20 miles, but time and 1000 distance have an uncertain relationship in rural Sierra Sub-Saharan Africa Leone. Theunnamed girl and her unborn child wait, the risk to one or both of their lives rising everyminute. 500 World ierraLeone’s dubious distinction is not justits supposedly record-breaking rateofmaternal death. 0 SAWorld Bank line graph plotting the World Health 1990 92 94 96 98 2000 02 04 06 08 10 12 15 Organisation’s estimated maternal mortalityrates for low-income countries over the past25years shows war Source: World Bank

44 |FT.COM/BIRTH 2.

Before theEbola outbreak deaths were nothabitually reported—they were afamily or communitymatter

World Bank is exaggerating SierraLeone’s problem by a factor of four.Either that, or about another 1,000 Sierra Leonean women died maternal deaths in the firsthalf of this year,and Dr Sesayhad no wayofknowing about it. Before the Ebola outbreak deaths were not habitually reported to the government in SierraLeone. The business of death is astrictly family or community matter and the reports were of little value to the state. But when the outbreak came, data on who died, where and how,suddenly became vital to stem its spread. Reporting everydeath was made mandatory. Initially,people were resistant, dreading the prospect of their loved ones being slung into the next life by astranger in ahazardous materials suit. However, zones such as South Sudan and the Central African 1. more resources were mobilised and surveillance Republic closely bunched together.But SierraLeone’s Advice is dispensed increased at the communitylevel.There was asurge line, while decreasing gradually from ahigh during its at the Tikonko in reporting across the nation. But as the epidemic community health own 1990s war,isextraordinary. clinic in Bo District abated, so too did the higher rates of death reporting. It floats high above the whole motleycrewat1,360 2. Now, according to the ministryofhealth’s own maternal deaths per 100,000 live births as of 2015. This Hawa Koiholds her surveillance update for September 2016, only around a estimated ratio is almostthree times higher than the babyNaasu after quarter of all deaths are being reported. averagefor sub-Saharan Africa. If the figures are correct, returning home Theministryofhealth requires poorly paid community around 3,100 women will have died maternal deaths last health workers to reportmaternal deaths to health year alone; 3,956 men and women died in SierraLeone facilities, which in turn mustreporttodistrict-level during the Ebola outbreak of 2013-16. Thestatistics are a medical teams. Possible weak links abound in this mark of continuing infamyfor the country. system, not leastbecausethose government employees “Weneed to saysomething about those figures you are doing the reporting are the same people under pressure using,”saysDrSantigie Sesayathis office in Freetown, to ensure thatmothersdonot dieintheir communities. SierraLeone’s capital. Dr Sesayisthe government’s director of reproductive and child health, responsible fewdaysafter my meeting with Dr Sesay, ababy for coordinating the state’sresponse to maternal death. girl called Naasu Koi arrives into the world “We’ve putinplace amaternal death surveillance and Aat the Tikonkocommunityhealth facilityin response team, and developed atechnical guideline. neighbouring Bo District. Hermother,HawaKoi, has When adeath is reported, theygoand confirm.” attended prenatal classes at the clinic throughout her It sounds simple. From JanuarytoAugustthis year, pregnancyand made the two-mile journeyfromher 432 maternal deaths were recorded by the ministryof villagetodeliver her fourth baby into the familiar arms health and sanitation. According to their figures, even of nurse Irene Moseray.Itisatextbook birth. allowing forsome under-reporting, the collective wisdom Koi’smother-in-law, Miatta Momoh, who is older of the WHO,Unicef, the UN Population Fund and the than she can remember,sits on ahard wooden bench

FT.COM/BIRTH | 45 SIERRA LEONE MATERNAL MORTALITY

1.

1. outside, waiting to see her latestgranddaughter.The Just thatweek, ahorror storywas doing the rounds Pregnantwomen wait blue wall behind her has layers of faded posters from UN at the ministryofhealth. It concerned apregnant foracheck-up at the and non-governmental organisations —adverts for a 13-year-old who had died recently in Bombali, in the Tikonkocommunity health clinic different life. They tell her to consider an intrauterine north of the country. ATBA had locked her in ahouse 2. device, to “use Mr Condom”and to getchecked for Aids. during labour and by the time the communityhealth Documentation at Childbirth was adifferent experience for her,conducted worker brokedown the door,itwas too late. Theimageof the clinic at home with the help of senior women from the the government representative, an outsider,trying to kick 3. community—known as traditional birth attendants down adoor locked by the trusted TBAseemed Massa Amadu with three of her adopted (TBAs). Sometimesmothers died, but no one was emblematic. While health workers mayhaveaccess to the children —Hassan, blamed. “Itwas the will of God. And if there was adelay medicine, it is often the TBAs who have patients’ trust. fiveweeks,Kadiatu15, in delivery, theywould ask thatwoman. ‘Whathaveyou Pragmatic solutions are needed. At Naasu Koi’sbirth and Joseph, 18 months done?Please tell us. Have you done something wrong to in Tikonko, twoformer TBAs watched as the nurse your husband?’”Momoh laughs. “But these things used delivered. Since 2014,aspartofaprojectpiloted in Bo to work to getthe woman to deliver!” DistrictbyConcern Worldwide, an international NGO, Thegovernment concluded TBAs were adangerous 200 former TBAs have been trained and rebranded as anachronism and tried to ban them from assisting births. MNHPs(maternal and newborn health promoters). In 2010, it launched afreehealthcare initiative for Instead of delivering babies in isolation, theyvisit, 2. pregnant women, lactating mothers and children under encourage, check for danger signs and refer pregnant five. By-laws proscribing home births and imposing mothers to healthcare facilities. Thesmall amount of severe fines for mothers and those facilitating were also moneyand social status theypreviously attained through brought in. But TBAs are afundamental partofthe deliveries is now made through selling essential items to traditional structures thatgovern mostpeople’s lives and, the mothers theyvisit. Rather than women being locked unlikegovernment health clinics, are present in every away from government healthcare, the TBAs’familiarity village. While facilitydeliveries did increase, by 2013, the and influence in communities is being harnessed to help lasttime the country’sdemographic and health survey mothers access it. was conducted, half of births in rural areas were still According to the nurses at Tikonko, backed up by the taking place at home. town chiefresponsible for enforcing the communityby-

46 |FT.COM/BIRTH Amadu began to visit aherbalist in adistant village. The Theimage of agovernment elephantiasis reduced. It was from the same villagethat she adopted Hassan. Around his neck is atinyamuleton representative trying to astring. She puts my finger on his head gently,locating asmall hole. “It’sthe traditional remedy for this,”she kick down adoor says. Thehollow is Hassan’s anterior fontanelle, which can be felt in almostall babies. When it eventually closes, seemed emblematic as it does in all children, Amadu will conclude thatthe charm played its role. “I takeitoff when Itakehim to my hospital though,”she laughs. “Wetell the patients not to laws, Naasu Koi’sbirth was typical. No women in the area use traditional medicine”. has given birth at home in the pasttwo years, theysay,and ForAmadu, as for manypeople in SierraLeone, no one could remember amaternal death. At three more traditional and modern medicine are complementary remote rural clinics, in Bo and then Moyamba district, I rather than in opposition to one another.Decisions am told the same story: maternal death doesn’t happen, on which to use might be based on whatismosteasily not in this community, not anymore. Death is elsewhere. available, whatseems to work or where one feels most respected. In childbirth, this presents achallenge. Mortality ratesin he next dayImeetMassa Amadu, a32-year-old Some mothers will exhausttraditional remedies before SierraLeone nurse from Freetown sent to work in Moyamba City. seeking medical help. In remote areas, this leads to TChildren fill everyspace in her small house. She has death. Howtochangethis behaviour is partofabroader adopted six, three of whom have losttheir mothers in international development conundrum about how the pasttwo years in pregnancyorbirth-related deaths. traditional practices viewed as harmful can be changed. She thrusts the youngest, five-week-old Hassan, into my At the Tikonkohealth facilityattendees at the monthly hands. “His mother needed blood and there was none. She 10am antenatal class file in after noon. Some have had already borne 10 children,”she says. walked up to five miles from villages while pregnant, and 1,360 She has one son of her own, back in Freetown. “But their fatigue shows. Eventually nurse Moseray begins a maternal deaths per Ishould have two,”she says, showing ablurred picture nutrition class, describing pictures of the correctfood for 100,000 livebirths on her phone. It is of adead baby,Foray,wrapped in a pregnant mothers. Thewomen’s eyes glaze over,soshe white swaddle. He was the productofarelationship with and TBASusan Pormeh produce agourd rattle. It brings aman who, unknown to Amadu, was already married. the listless women to their feet, dancing, clapping and When his wife found out, problems began. “She took chanting enthusiastically in the local language, Mende, me to the herbalist—she wanted me to die.”Foray died to an easily memorised song about good nutrition and 120 in his sleep soon afterwards and Amadu ended up with hygiene. severe elephantiasis. She believes both misfortunes were This approach mimics one used in SierraLeone’s deaths of children under fiveper punishments —products of the jilted wife’scurse. traditional secretsocieties, where song and dance 1,000 livebirths When the medicine her hospital gave her didn’t work, predominate as teaching and expressive forms. Paul Richards, an anthropologistwho has worked in Sierra Leone for more than 40 years, has recently published a book about Ebola. In it, he describes a“people’s science” 3. through which communities have changed their cultural norms around burial practice and traditional healing. In Richards’ view, beliefisformed by social action, not vice versa. In Tikonko, the gourd rattle seems as important a tool as the stethoscope in promoting maternal health.

owever high SierraLeone’s true maternal mortality ratemight be, no single intervention can fix it. HWhether through access to family planning, medication, prenatal care, emergencyobstetrics, training of health staff, an effective referral system —not to mention tackling longstanding structural violence against women —the tide mustraise all these boats at once. Old culprits such as corruption and inefficiencystill hinder progress and there is insufficient funding for the task. Theunderlying challengeisthe need to bridgedivides and suspicions between the helpers and the helped. In Tikonko, Moseray and Pormeh’s method of interaction with the women is vital. Thenurse is both an insider and outsider —aformal practitioner,but one who can speak the local languageand does not patronise, embarrass or hector.Incombination with the provision of good- qualityservices, this is whythe women have turned up today, and whytheywill return to give birth. “The nurse is kind here,”asHawaKoi says. Perceptions of the state, and the qualityofhealthcare it offers, are not

FT.COM/BIRTH | 47 SIERRA LEONE MATERNAL MORTALITY

1.

1. and 2. always so positive in acountrywhere some citizens, The girl broughtfrom confronted by the Ebola outbreak, concluded thattheir Rotifunk in labour with own government was trying to kill them. Thedistance complications gave birth by caesarean between the urban and rural worlds, the deficit between section in the hospital the government and the governed, is wide. in Moyamba Back in Freetown, Dr Sesay, in casting doubt on the WHO estimates, also identified adubious utility for some in SierraLeone’s ignominious record of the worstmaternal death rates in the world. “These people [NGOs] need verybad numbers to sell to their donors and makemoney,”hesays. “So mostofthe time theygive out the negative partofit.” By email, Dr Lale Say, co-ordinator of the WHO’s 2. department of reproductive health and research, reiterated thatthe estimates are not precise figures, and encouraged caution making comparisons between youthful 32-year-old, decides on acaesareansection. countries. “The lower and upper estimates should be In the operating theatre the following morning, considered in such assessments,”she wrote. However, surrounded by 11 hospital staff, he cuts open her even using the WHO report’slower estimate, Sierra belly and pulls out atinypink body from the red: a Leone, would still have the highestration in the world. boy,premature. Theumbilical cord is cutand the Sonnia-Magba Bu-Buakei Jabbi, seniorstatistician at motionless, soundless baby is placed on abright African SierraLeone’s government-funded independent statistics lappa cloth incongruous againstthe clinical white and body was clear: “Ministryofhealth and sanitation blue of the medical staffsmocks. Amucus aspirator officials are justtrying to paint aprettypicture.” is pushed into his nose and throatand pumped, fluid sucked out again and again. Themidwives lifthim ythe time Elie and his ambulance finally arrive naked by his feet, vigorously massaging his back, trying back at the Moyamba government hospital carrying to inspire circulation. B Hismother needs atransfusion, and she is lucky: the unnamed girl from Rotifunk, afull five hours have passed since her call for help. Herbaby has still not her blood type is common and the hospital blood bank come; the mother —probably younger than 17 —isjust is not emptythis time. As the doctors sewher back too small and her pelvis not wide enough. It is not clear up, her son finally coughs his wayinto life. There is a whether the baby is even alive. murmur of laughter among the deliveryteam. They Hospital superintendent Dr James Jongopei, a have saved alife —two lives.

48 |FT.COM/BIRTH INNOVATORS UGANDA On theroad

Ascheme to bringhealthadvice andmedicineintothe home. By Andrew Jack

Theproject Living Goods, aUSnon-governmental organisation, in partnership with Brac,the microfinance social enterprise, managesanetwork of paid community workerswho provide health education, diagnoses, referrals and affordable treatments to villagersinUganda.

Theneed Manyhealth systems areunderfunded or badly managed, resulting in high unnecessaryillnessand death. Theyare often inaccessible,unattractiveorunder-staffed and without medicine stocks. Sometimesinmoreremoteareas, theyare supportedbyunpaid community health volunteers whoare well-intentioned but frequently overstretched unsupervised or not supplied with medicines.

Howitworks Inspired by Avon Ladies(who sell cosmetics door to door), Living Goods recruits trusted local independent part-time agents, trains them and pays them modest commissions on salesof essential medicinesand other commoditiessuch as waterfilters. Each goesdoor-to-door across acatchment area of 150-200 households and providesfreehealth education and diagnosis using tools such as a SmartHealth app that drawsonofficial health guidance.Theyreceiveadditional incentives to register pregnant women and visit them 48 hoursafter birthtocheck on the health of the mother and child. In total, theyearn $10-$20 a month. Service delivered to thehome can be “cheaper than free” by removing the time and cost of travelling to clinics.

Theimpact Living Goods plans to reach5mpeople by the end of 2016.It costs $2 per person per year in the catchment area.Astudy published this year suggested the programme reduced under-fivechild mortality by 27 percentcompared with districts without the service.Ithas spreadthe model to Kenya, and has worked with partnersinZambia and Myanmar.

What is needed next? • Fundingtoexpand the project across Uganda and Kenya, providing scale and achance to test howitoperates as a national programme. • Partnership with government and multilateral donorsto contract directly with the organisation to provide community health services. • Corporateconnectionsfor supportinkind, including the supply of smartphones, SMS,new products, servicesand medicines. • Newcountrieswilling to explorethe modeland develop a community health policy. • Linkswith other organisations in target countriesontowhich Living Goods can piggy-back to expand. • Advocacygroups to shareexperiencestolobbyfor improved community healthcare.

Want to help? Email: [email protected]

FT.COM/BIRTH | 49 NIGERIA FAMILYPLANNING

‘Weneedtoreduceour populationnow because we arefacinghuge economic challenges’

in the conservativenorth influence how manyyears of schooling girls and young women are allowed before marriage. Most girls in the impoverished north-westgive birth in their mid-teens, according to the Demographic and Health Surveys Program, the US data provider. Nigeria has one of the highestmaternal mortality rates in the world —814 deaths per 100,000 live births.

S According to the UN,the countrymakes up about 2per

GE cent of the world’s population but 10 per cent of total

IMA maternal deaths. Underlying these figures are deep TY disparities between the regions. ET

/G Thecountry’scommercial capital, Lagos, is acentre of FP innovation in the continent’s tech start-up world. But a :A

TO woman’s chance of dying apregnancy-related death in Nigeria is one in 13, according to the UN,while justone- PHO third of deliveries are with skilled birth attendants. Public health expertssay that, in northern Nigeria in particular —which is far less developed and prosperous than the south —studies show thatwomen are having ‘Having30children more children than theysay theywant to. This is asign theymay not have access to family planning options, control over their reproductive lives or the chance to in onehouse makeany decisions at all about their lives. “It’snot justabout family planning alone,”says Babatunde Osotimehin, executive director of the UN is notgood’ Population Fund. “It’salso ensuring women and girls are empowered with education.”HesaysUNagencies are engaging with political, religious and traditional leaders High fertility ratesand an economic crisis slow in the north in particular to find “champions within progress on maternal health.ByMaggie Fick society who understand whatweare trying to do”. While some traditional leaders have begun to speak publicly about the importance of family planning and “spacing”for thesakeofamother’s health and thatofher omen in northern Nigeria have an Mortality rates future children, politicians from the northern region are averageofmore than seven babies. in Nigeria loath to speak up on apersonalmatter thatisentwined But nurse Aisha Saraki knows with cultureand religion. whyshe and her colleagues in the “The political elite are the missing bit of the jigsaw,” maternityward at one of northern says adevelopment official in Abuja, who did not want to WNigeria’sbiggest hospitals are not be named. busier these days. “There is no money,”she begins, Some of the fewpeople who are willing to speak referring to the economic recession battering Africa’s directly are female students who are trying to beat biggest oil producer.“And theywant something to eat,” 814 the odds by staying in school. “Weneed to reduce our she says of expectant mothers in the area. maternal deaths per population now because we are facing hugeeconomic Increasingly,women in the northern cityofGusau 100,000 livebirths challenges,”saysZainab Garba Jijji, aged 17.“Having 30 are choosing to save moneybyhaving their babies at children in ahouse is not good. Thegovernment needs home. Atrouble-free deliveryatthe privately owned to tell people the truth.” hospital costs the equivalent of $11, according to Saraki. Saraki, the nurse, agrees but says financial strains That makes ahospital deliveryunaffordable for most caused by low oil prices will slow the government’s Nigerians. AUNstudy lastyear found thatmorethan 60 progress on critical issues such as education for girls, per cent of the population live on $1.25 aday. 109 who will getmarried young and begin having high-risk Agrowing economic crisis, amid already severe deaths of children pregnancies if theydonot stay in school. “Through poverty in places such as Gusau, is the latestobstacle to under fiveper education, women are now understanding the problems efforts to rein in maternal mortality. But it is far from the 1,000 livebirths they’ll suffer”from home deliveries and multiple only factor.Deeply rooted cultural andreligious norms pregnancies in rapid succession, she says.

50 |FT.COM/BIRTH INNOVATORS NIGERIA KwaraCare

AwestNigerian statewants to make healthinsurance affordable. By Andrew Jack

Theproject The government of the west Nigerian stateofKwara, US medical insurance agencyHygeia, the Netherlands government and health insurance fund PharmAccess Foundation have createdthe first statehealth insurance programme in Nigeria, to provide affordable and quality healthcarefor poor people.

Theneed Nigeria has the largest population in Africa.Yet this country, wheremost people livebelow thepovertyline, has some of the world’shighest maternal and child mortality rates. Nearly three-quarters of medical costs arepaidbypatients out of their ownpocket, discouraging access to quality healthcare.

Howitworks The scheme offersprimary and limited secondary healthcareservices, with premiums from poor people subsidised by the Dutch Health Insurance Fund and increasingly by Kwarastate.Servicesare provided by both public and private healthcarefacilities, which must participateinamedical quality improvement process. Thereisanextensiveevaluation process.

The impact Nearly 350,000 people have enrolled on the scheme and have made almost 1m visits to 42 facilities. The latestevaluation in 2013 concludedthe scheme offered “considerable positive impact”. Those coveredbythe scheme took fargreater advantage of modern healthcareand spent less of their own moneyonhealth. Hospital deliveriesrose 77 percentand therewas some evidence of adecline in hypertension. The cost was$28 perperson per year.

Plansfor thefuture Theaim is to shiftfromexternal funderstolocal resources, and to expand coverage to allresidents of Kwarastate.A statehealth insurance lawhas been developed and sent by the governor of Kwarastate to theKwara HouseofAssembly fordiscussionand adoption. The lawisdesigned to create mandatorystate health insurance,wherebyricher people will cross-subsidise the poor.Since last year,Kwara statehas been working on ahealth insurance fund.

What is needed next? • Politicalsupporttocreatethe state-wide health insurance system and to encourage similar approacheselsewhere. • Technical advice forfine-tuning the health insurance system foradiverse population; training; and the creation of the planned statehealth insurance agencytohandle issuessuch as management, contracting, monitoring and auditing. • External funding foranestimated $5m initial capitalisation for the statehealth insurance fund, plus continued supportofthe low-income premium subsidy afterthe end of2016.

Want to help? Email: [email protected]

FT.COM/BIRTH | 51 CHAD FERTILITY ‘God gave me this bigfamily’

Centuries-old social traditions andpoverty have trapped Chad in acycle of high birth ratesand highmortality

By Andrew Jack in Lake Chad Photographs by Kate Holt

alngaye Adam grimaces as he squats on amat in ahot,dusty compound in Tagal, avillageofone-storeymud and wooden houses on the shore of Lake Chad. “Life has become verydifficult,”he Msays, flanked by his wife and 10 children. In the country’ssouthwestern Lacregion, flooding, raids by radical Islamic BokoHaram militants —and government-forced displacement in response —have squeezed the amount of land he has to cultivate. Drought has reduced his crop of maize to afraction of previous levels. Arecent influx of refugees from neighbouring Nigeria —and the accompanying aid workers —has pushed up food prices. He glances round at his nine boys and single girl, unable to recall their precise ages, and says he cannot poorestcountries with the fourth highestfertilityrate. afford to paythe fees to send anyofthem to school. With an averageofnearly seven children per mother “It’samatter of pride to have abig family,” he says. —and rising —the countrydefies the typical global “Lots of children help you. It was not my choice. pattern of so-called “demographic transition”. Normally, Godgavethem to me.” improved health and development reduces early deaths He married his wife, Kattouma, when she was 15 and and afall in birth rates follows, resulting in abalanced he was 22. He is now 52. “If she had given me only two population for each agegroup. children, Iwould have taken asecond wife —ifI’d had Thepopulation of Chad, however,isaround 13m and the money,”hesayswith asmirk. But, as she breastfeeds growing at 3.5 per cent ayear,with two-thirds of its her nine-month-old youngest, Kattouma says firmly people aged under 25. Without greater efforts to limit thatshe has had enough children and would have used this expansion, expertswarn thatChad risks missing contraception had she known about it earlier. out on the “demographic dividend”—asurgeofpeople Their situation is typical in Chad —one of the world’s entering the workforce to boosteconomic growth.

52 |FT.COM/BIRTH Amatterofpride Instead, rising overall numbers of young dependents camels and long-horned cattle than cars, traditional Malngaye Adam, right, in Chad are exacerbating health and nutrition problems, practices prevail. Thelocal chief, Ali Koura, preaches with his wifeKattouma triggering conflicts and forcing communities to spread the merits of “family limitation”and says thatfive or six and their 10 children in the village of Tagal in anygains verythinly at the expense of improved services. children are sufficient, although he has 13 by five wives. the Lake Chad basin “I tell heads of statethatthe bestassettheyhaveis In anearby walled compound of huts, Ashta their people,”saysBabatunde Osotimehin, aformer Mohammed, now aged 22, says she was forced by her health minister of Nigeria and now executive director parents to marryat14and had the firstofher four of the UN Population Fund, which is active across the children within ayear.“Isuffered alot,”she recalls of the region in promoting improved family planning. “Young birth, saying she would now liketopausefor three years. people can transform societies, but if you have so many But she sees herselfeventually having afamily of at least it’s not sustainable.” eight. “[Having] lots of kids will help me.” In Tagal, atwo-hour drive from the Lacregion’s capital In Africa’sfifth-largestcountry, which sits on of Bol along ruggeddeserttracks more often used by significant oil reserves, some pronatalists argue there CHAD FERTILITY

1.

54 |FT.COM/BIRTH ‘Thisisaninsular population living precariously,in ignorance, with no education or health infrastructure’

is no need for birth control, with plentyofland to go round. Thedifferent tribes and faiths vie for influence and are concerned about security, withhostileneighbours across the largely uninhabited northern and eastern sub- Saharan desertregions, including Libya and Sudan. Most of Chad’s population is concentrated in pockets of the westand themore verdant south, where rising fertilityrates are driving malnutrition and unnecessary deaths of mothers and infants as well as creating environmental pressures such as over-fishing and farming and desertification of agricultural land. As 2. resources are squeezed, periodic conflicts break out. “Things have become difficult,”saysMohammed Kale, one of Tagal’s manyfishermen. “There is less water and too manypeople are fishing. Tenyears agothere were 1. space is the same. There are tensions between farmers and plentyoffish. NowIcatch asixth as much and mostof Youssef Mbodou cattle herders. Everyone wants land,”hesays. them are smaller.I’m only 40 years old, but Ihavegrey Mbami, the traditional Hisfamily has provided leaders in the region for six chief of the Bolregion hair from the stress of looking after myeight children.” 2. and3. generations. He himself has 15 children, and he stresses Fishermen at work underlying causes in the isolated, landlocked country nBol, YoussefMbodouMbami, Chad’s former on the lakebythe thathelp account for unrestand high fertility.“This is an ambassador to Niger and Nigeria who has returned to village of Tagal, where insular population living precariously,inignorance and Ihis roots as the traditional leader for the region, points to resourcesare under with no education or health infrastructure,”hesays. increasing pressure long-standing but intensifying feuds linked to nomadism Theneglectofthe population’s social needs reflects and transhumance (the moving of cattle in search of both the legacyof60years of colonial rule by the French pasture). “The number of people has increased but the and half acenturyofinstabilityand conflictsince independence in 1960. Long before the displacements triggered by the rise of BokoHaram in the pastthree 3. years, militaryand securityactivities dominated government. Foreign powers, with an eyeoncontaining Islamic extremism, have also focused on Chad’s strategic importance, ignoring the need for domestic reform. There is alargeFrench militarybasenear the airportin the capital N’Djamena and anew multistorey, fortress- likeUSembassy is being constructed on the outskirts. Health accounts for less than 7per cent of the state budget and, with mostpeople required to payout of their own pocket even for nominally free public services, total spending on health was just3.6 per cent of gross domestic productin2014, according to the World Bank, compared with 17.1 per cent in the US and 8.8 per cent in South Africa. This lack of investment helps explain both the high rates of infection and death and the scant use of family planning. Supply and demand for modern forms of contraceptives are among the lowestinthe world, with surveys suggesting theyare used by less than 5per cent of women in Chad.

FT.COM/BIRTH | 55 CHAD FERTILITY

‘The cultureremains impenetrable. People think of girlsaswomen as soonas they reachreproductiveage’

ore indirectwaystolower fertilityare also absent. Literacyfor girls is at 20 per cent and just12per Mcent even startsecondaryschool. Instead, nearly 68 per cent are married before the ageof18and 29 per cent before theyreach 15, according to Unicef. Girls begin giving birth while theyare still physically immature, leading to complications such as obstetric fistula (internal tearing during childbirth thatleads to incontinence). They then face along reproductive cycle, often marked by inadequate spacing between births, and the inabilityto produce sufficient breastmilk to feed their children. “Here, the woman has no power,” says BakarySogoba, head of child protection for UnicefinChad, drawing a contrastwith neighbouring countries thathavelower fertilityrates. “InMali, there is along tradition of travel. Chad is less open to the exterior.The cultureremains impenetrable. People think of girls as women as soon as theyreach reproductive age—theyare sometimes even promised to aboy at birth. And where there is polygamy, you can have competitive reproduction between multiple wives vying to have more children than their rivals.” “There is progress, but it’s not enough,”saysMoussa Khadam, Chad’s minister of public health, whose grandfather had 63 children but who has limited himself to two. “Chad has veryhigh illiteracyand is already overpopulated in the centre and the south. We need better tools for family planning and greater awareness to tackle traditions thatare centuries old.” Mortality rates Such practices explain whyChad ranks among the When public moneyisprovided, however,itisnot in Chad world’s worstperforming countries in terms of health. always used effectively.Behind Khadam’s ministry With maternal deaths of 856 per 100,000 live births in building in N’Djamena are more than 100 unused 2015, and infant deaths of 85 per 1,000 live births, life ambulances neatly parked among growing weeds; expectancyatbirth is just53.1 years. In part, the country none of them even has anumber plate. Even if theyare has not experienced the demographic transition because eventually deployed as intended, and do not quickly manyofthe pre-determinants are not yetinplace. break down on the country’sfew passable roads, many Having more children remains away to replace those see them as awasted investment. 856 who do not survive. Rolland Kaya, countrymanager for the Médecins maternal deaths per Sans Frontières humanitarian aid mission in Chad, 100,000 livebirths tatherapeutic feeding centre in N’Djamena, argues thatmuch more public funding should go into Nelkam Dadimra, who is barely 15, cuddles her supporting basic prevention methods and local health Amalnourished 10-month-old daughter,Salut. She clinics. “Often there are no supplies, no vaccines, no came to the capital three years agotofind work as a bed-nets againstmalaria, no hygiene training to stop cleaner and gave birth at home, leading to complications infection, and workers are not paid,”hesays. and stomach pains from which she still suffers. Unable Theresult is thatpeople turn instead to traditional 139 to breastfeed, she fed her child amilletporridgemade healers, whose interventions often makematters deaths of children with water which she is too young to digest. This has worse. He cites strangeherbal concoctions, incisions under fiveper caused diarrhoea and fever.“Godgives us children,” made into the skin as supposed treatments and, in one 1,000 livebirths she says. “Maybe Iwill have 10.” case, aremedy for diarrhoea thatinvolvedburning the With malnutrition affecting 40 per cent of Chad’s affected young child’s anus. children, Dr Ibrahim Dicko, who runs the centre, says he

56 |FT.COM/BIRTH sees such cases frequently.One reason is the extremely lowuse of exclusive breastfeeding by mothers, partly because of abeliefthatifeither mother or child is ill, breastmilk will be harmful. “Theygive herbs, ashes, buy powdered milk and mix it with water,” he says. “Gastroenteritis is verycommon.” While mostofthe 100 children currently being treated at the feeding centre need at leastseven days’ care, Dr Dickosaysmothers sometimes takethem home sooner while theyare still ill, or even abandon them. “Husbands want their wives at home, and there is family pressure to look after the other children. They think theycan always have more.” At afamilyplanning clinic in N’Djamena’smain market,where women can slip in discreetly while selling or shopping, Josephine Nangtan, acounsellor, gestures towards abox on her desk containing dozens of registration cards. “Theyask me to keep them here, because if their husband sees them, it could be areason for violence or divorce,”she says.

ttitudes are beginning to change. Protestant Church leaders supportcontraception —not to limit Afamily size but to stress the need for a“responsible” number of healthychildren, starting later and spacing births. TheCatholic Church takes asimilar line, while stressing it only encourages natural methods. Thesame is true of Muslim leaders. Sheikh Abdaddayim Ousman, secretary-general of the Higher Council on Islamic Affairs, says: “The prophettoldustomarry and have a family of quality, not quantity. Islam also distinguishes between marriageand the consummation of marriage.” On paper,atleast, legislation passed in 2002 guarantees access to reproductive health in Chad, overturning colonial-eralawsthatbanned birth control and widespread practices that, until far more recently, required husbands or parents to authorise anyfamily planning. An official plan has setfour children per woman as an objective for the countryby2030. More radically,lastyear President Idriss Déby Itno 1. pushed through alaw banning marriagebefore the age of 18 —afirstinwestAfrica and amove possibly linked to his current international profile as the chair of the African Union. Khadam, the health minister,says some ‘Inrural areas, practically violations have already been prosecuted. Yetfor now,asAbbot Gabriel Dobade from the nothingisbeing done. Catholic Church’s Episcopal Conference, puts it, there are fewsigns of broader public investment in Chad’s We aregoing backwards’ development. “Inrural areas, practically nothing is being done,”hesays. “Weare going backwards in areas where we should be advancing. There is injustice 2. and poor governance.” After years of rising government revenues, the drop in the oil price in recent months has imposed fresh austerity. Theconference centre where the African Union was supposed to hold its meeting in N’Djamena lastyear sits unfunded and unfinished. Public sector workers 1. and students on grants have not been paid in weeks, Girls use the waters of Lake Chad to do triggering marches, strikes —including in health centres the washing —and stone-throwing by young people. 2. Just as the state’sability to investinhealth, family Nelkam Dadimra, 15, planning and other public services has been reduced, with her 10-month- the mostrecent swelling cohortofyoung people is old daughterata therapeutic feeding moving towards adulthood and is beginning to make centreinN’Djamena its frustration felt.

FT.COM/BIRTH | 57 COMMENT DESMOND TUTU

childbirth is one of the biggest killers of teenagegirls in thedeveloping world —and theirchildren face the same tragic odds. Marrying agirl young, often to amuch older man, is asure waytoinflictpoverty and inequalityinher community. But there is an alternative: to end this cycle is to free agirl to be safe and healthy—tolet her flourish and become who she wants to be, on her own terms. Five years ago, Iorganisedameeting with TheElders, an international organisation of former politicians, public figures and other oldies likeme, to ask child marriageactivists whatwecould do to help. They told us to speak out, thatreal changeneeded to happen at the grassroots. They said amovement was needed. Todayitisobvious theywere right. Nowstanding behind those activists —mothers, daughters, fathers, sons, teachers, imams, priests, rabbis —are countless communities determined to break the painful bondage of tradition. We helped them build acoalition, Girls NotBrides, which spans more than 80 countries and 600 organisations. HillaryClinton, then secretaryof state, told me she has made ending child marriageher personal commitment. There has been heartening progress. Last year, the UN made gender equalityone of its Sustainable Development Goals for 2030. In 2014,the African Union launched acontinent-wide campaign to end child marriage, encouraging its 54 member statestopass laws, makeaction plans and supportcommunities. In Nepal, anational plan to end child marriage ‘Child marriage involved ministries, local and foreign non-governmental organisations, academics, lawenforcement, journalists, and faith and communitygroups.The result was a harmsour human committed national movement with the spirit and vision to getthe job done. We are dealing with deep-rooted traditions: it is everybody’s job to help. As my friend family’ Graça Machel [the politician and widow of former South African president Nelson Mandela] says: “Traditions were made by people; theycan be changed by people.” Girlsshouldbefreetoflourishontheir own Even with better recognition, the problem continues terms, says Desmond Tutu to grow.The number of child brides rises each day. This year alone it will wrench 15m girls out of childhood. Thebiggest challengeistoacceleratechangein towns, villages and homes. Theactivists Ihavemet — illions of girls are married as children. in Ethiopia, India and, more recently,Zambia —are This factharms our human family hard at work convincing parents and communities and reminds us how deeply biased thatthere are alternatives to child marriage. But many our world still is againstmothers, of them don’t have the funds to match their courage. sisters and daughters. We now They deserve far more support. With support, these girls Mhave amoral dutytoend one of will win back their freedom: in Zimbabwe, Loveness and humankind’s mostdestructive traditions. Experts say Ruvimbo, twoyoung women forced to wed before they it is feasible in one generation. were 18 took their government to court. Child marriage Maybe because Iamaman, Ihavespent much of is illegal there unless parents allow it, which their my life ignorant of the scale and awfulness of child parents did. Zimbabwe’s Constitutional Courtruled in ‘Traditions marriage. But, in recent years, Ihavetalkedtomany the girls’ favour,bringing all of its children’s rights closer girls and women who have educated me. It wasn’t until to the full protection of the law. were made by my retirement thatIrealised thatone in three women in Iknow thatone generation sounds likeashorttime the developing world is married before the ageof18, or to turn the tide on apractice thatiscenturies old, but people;they understood whattheyrisk as aresult. thatiswhy old ones likemeare here to remind you S

Across the world, girls are powerless to choose when thatchangeisinthe air.Iftwo bravegirlsrefused to GE

canbe theymarry, to whom, or whether theymarryatall. give up, neither can anyofus. IMA

Theday of their marriageisthe daytheygive up school. TY changedby Under pressure to bear children, theycannot negotiate Archbishop Desmond Tutu received the Nobel Peace ET :G

safe or consensual sex. As pregnant young mothers, Prize in 1984 and is achampion of Girls NotBrides: TO people’ theyface the danger of injuryand death. Indeed, The Global Partnership to End Child Marriage PHO

58 |FT.COM/BIRTH